NURSING HEALTH HISTORY

I. BIOGRAPHICAL DATA
A. Name/Alias:
B. Address:
C. Age
D. Birth Date
E. Sex
F. Race
G. Marital Status
H. Occupation
I. Religious Orientation
J. Health Care Financing and usual source of medical care

II. CHIEF COMPLAINT AND REASON FOR VISIT

A. What brought you to the hospital/clinic?
B. What is troubling you?

III. HISTORY OF PRESENT ILLNESS

May not all be necessary, depending on the chief complaint; use judgment - may also need to
elaborate beyond these questions
A. Where it is located on the body (such as pain)
-Does it radiate
B. Timing
- When did it start / how long has it been going on?
- How often
- Is this a new problem / first time having this problem?
- Intermittent or constant?
- If intermittent, how long does it last, and how often does it occur?
C. Quality (particularly important if pain)
- Dull, sharp/knife-like, achy, pressure, tightness, tingling, etc
D. Severity or intensity (pain scale)
E. What triggers the symptom
- What were you doing when it started
- What causes it to occur
F. Alleviating / aggravating factors
- What helps it
- What makes it worse
G. Any other symptoms that you have?

IV. PAST HISTORY

A. Childhood illnesses
B. Adult illnesses
C. Surgeries
 D. Hospitalizations
E. Injuries
F. Trauma
G. Allergies
• Do you have any allergies?
• What usually is your allergic reaction?

H. Current medications
• Prescribed medications (also determine when started and if any doses have been changed
recently)
o Questions to ask about medications
- Name of medication
- Dosage and frequency / change in dosage (make sure you have correct units)
- The way the patient is actually taking it (don't assume it's the same as written)
- The reason the patient is taking the drug
- How long taking it
- Does the patient feel it is working
- Has the patient had any issues or side effects from it
- Compliance / remember or able to take it (can ask how the patient remembers to take
it)
o Remind of typically "forgotten" medications:
- Samples
- Birth control pills
- Creams/ointments
- Eye/ear medications
- Inhalers
- Recent / current antibiotics
- Clarify any PRN medications for frequency of use

V. FAMILY HISTORY OF PRESENT ILLNESS

A. Health and ages of patient's sibling, children, or ages at death and causes.
B. Illness in the family similar to the patient.
C. Familial incidence of rheumatic fever, hypertension, tuberculosis, diabetes, mental
illness, others especially as suggested by the present illness.

VI. SOCIAL HISTORY

May not need to ask all of these (use judgment)
A. Occupation
B. Tobacco/Alcohol
C. Illicit drugs
D. Caffeine use (if applicable)
E. Diet (especially if on a special diet; or should be on one but is not)
F. Exposure (if applicable, such as with infections)
G. Sexual partners (if applicable)
 H. Living situation
I.. Ability to perform activities of daily living (if applicable)
J. Recreation
K. Safety situations (i.e. abuse; if applicable)

VII. FUNCTIONAL HEALTH PATTERN

A. Health Perception and Health Management Pattern
1. How has the general health been?
2. Any colds in the past?
3. Most important things done to keep health? You think these things make a difference
to health? Include family, folks, and remedies if appropriate.
4. Use of cigarettes, alcohol, drugs? (Perform Breast Examination?)
5. In the past, has it been easy to find ways to follow things Nurses/doctors suggestions?
6. If appropriate: What do you think caused the illness? Actions taken when symptoms
were perceived? (Results of action)
7. If appropriate: things important to you while you are here in the hospital or clinic? How
can we be most helpful?
8. Traditional Concepts of health and illness? Beliefs and practices?
9. (Classify what ill-health model is being used by the patient.)

B. Nutritional and Metabolic pattern

1. Typical daily food intake? (Specify) Supplements?
2. Typical daily fluid intake? (Specify)
3. Weight loss/ gain? Amount?
4. Appetite?
5. Food or eating discomfort? Diet restrictions?
6. Wound healing?
7. Skin problems? Lesions? Dryness?
8. Dental Problems?
C. Elimination Pattern.
1. Bowel elimination pattern. (Describe) Frequency? Characteristics?
Discomfort?
2. Urinary elimination pattern. (Describe) Frequency? Discomfort? Problem in control?
3. Excessive perspiration? Odor problems?

D. Activity- Exercise Pattern

1. Sufficient energy for completing desired required activities?
2. Exercise pattern? Types? Regularity?
3. Spare time: leisure activities? Child: activities?
4. Perceived ability for (Code Level)
Level (0) -Full self-care
Level (1) - Requires use of equipment or device
Level (2) - Requires assistance or supervision from another person
Level (3) - Requires assistance or supervision from another person or device
Level (4) - Dependent and does not participate
E. Sleep-Rest Pattern
1. Approximately how many hours do you sleep at night?
2. Any problem falling asleep? Do you take any sleep medications?
3. Is your sleep continuous? Tired?
4. Take naps? When? (Morning/Afternoon)
5. What do you do for relaxation? (Watch TV, listen to radio, read, dance, shopping)

F. Cognitive-Perceptual Pattern
1. Hearing difficulty? Hearing Aid?
2. Vision/ Wear eyeglasses?
3. Any change in memory lately?
4. Easiest way to remember/learn things? Difficulties?
5. Any discomfort? Pain? How do you manage it?

G. Self-Perception and Self-Concept Pattern

1. How do you describe you self? Most of the time, feel good (not so good) about
yourself?
2. Changes in your body or the things you can do? Problem to you?
3. Changes in way you feel about yourself/ of your body? (Since illness started)
4. Find things frequently make you angry? Annoyed? Tearful? Anxious?
Depressed? What helps?
H. Role - Relationship Pattern
1. Live alone? Family? Family Structure (Diagram)
2. Any Family problems you have difficulty handling? (Nuclear/Extended)
3. How does family usually handle problems?
4. Family depends on you for things? If appropriate: how are the managing?
5. If appropriate: How Family / others feel about your illness/hospitalization?
6. If appropriate: problem with children? Difficulty handling?
7. Belong to social groups? Close Friends? Feel lonely frequently?
8. Things generally go well with you at work? (School/college)? If appropriate income
sufficient to needs?
9. Feel part of (or isolated in) neighborhood where you are living?
I. Sexuality- Reproductive pattern
1. If appropriate: any changes or problems in sexual relations?
2. If appropriate: use of contraceptives? Problems?
3. Female: When menstruation started? Last menstrual period? Menstrual problems?
Para? Gravida?
J. Coping-Stress Tolerance Pattern
1. Tense a lot of the time? What helps? Use of any medicines, Drugs, alcohol?
2. What is most helpful in talking things over? Available to you now?
3. Any big changes in your life in the past year or two?
4. When you have big problems (any problems) in your life, how do you handle them?
5. Most of the time, is this (are these) methods successful?
K. Value Belief Pattern
1. Generally get things you like out of life? Most important things?
2. Importance of religion in your life? If appropriate: does this help when difficulties
arise?
3. If appropriate will being here interfere with any of your religious practices?
VIII. OTHERS
1. Any other things that we have not talked about that you would like to mention?
2. Questions?