HEALTH ASSESSMENT (ADULT)

NURSING HISTORY
BIOGRAPHICAL DATA:

Name:
Address:
Room number:
Age:
Gender Marital Status:
Birth date: Number of Dependents:
Birthplace: Ethnicity/Nationality:
Educational Attainment:
Occupation:
Referral (primary care physicians/practitioner)
Medical Diagnosis/ Impression:

SOURCE OF HISTORY

1. Record who furnishes the information – usually the person herself or himself, although the source may
be relative or friend.
2. Judge how reliable the informant seems and how willing he or she is to communicate. A reliable person
always gives the same answers, even when questions are rephrased or are repeated later in the
interview.
3. Note any special considerations, such as the use of interpreter. Sample statements include.

Patient herself, who seems reliable

Patient’s son, John Ramirez, who seems reliable.
Mrs. R. Fuentes, interpreter for Theresa Castillo who does not speak English.

REASON FOR SEEKING CARE

This is a brief spontaneous statement in the person’s own words that describes the reason for the visit. Think of
it as the “title” for the story to follow. It states one (possibly two) symptoms or signs and their duration. A
symptom is a subjective sensation that the person feels from the disorder. A sign is an objective abnormally that
you as the examiner could detect on physical examination or in laboratory reports. Whatever the person says is
the reason for seeking care is recorded, enclosed in quotation marks to indicate the person’s exact words.

“Chest pain” for 2 hours.

“Earache and fussy all night.”
“Need yearly physical for work.”
“Want to start jogging and need for checkup.”

The reason for seeking care is a diagnostic statement. Avoid translating it into the terms of a medical
diagnosis. For example, Mr. J. King enters with shortness of breath, and you ponder writing “emphysema”.
Even if he is known to have symptoms from previous visits, it is not the chronic emphysema that prompted this
visit, but rather the “increasing shortness of breath” for 4 hours.
Some people try to self-diagnose based on similar signs and symptoms in their relatives or friends, or
based on conditions they know they have. Rather than record a woman’s statement that she has “strep throat,”
ask her what symptoms she has that make her think this is true and record those symptoms.
Occasionally a person may list many reasons for seeking care. The most important reason to the person
may not necessarily be the one stated first. Try to focus on which is the most pressing concern by asking the
person which prompted him or her to seek help now.

PRESENT HEALTH OR HISTORY OF PRESENT ILLNESS

For the well person, this is a short statement about the general state of health.
 For the ill person, this section is a chronologic record of the reason for seeking care, from the time the
symptom first started until now. Isolate each reason for care identified by the person and say, for example,
“Please tell me all about your headache, from the time it started until the time you came to the hospital.” If the
concern started months or years ago, record what occurred during that time and find out why the person is
seeking care now.

As the person talks, do not jump to conclusions and bias the story by adding your opinion. Collect all
the data first. Although you want the person to respond in a narrative format without interruption from you, your
final summary of any symptom the person has should include these eight critical characteristics:

1. Location. Be specific; as k the person to pint to the location. Of the problem is pain, note the precise
site. “Head pain” is vague, whereas descriptions such as “pain behind the eyes”, “jaw pain and
“occipital pain” are more precise and are diagnostically significant. Is the pain localized to this site or
radiating? Is the pain superficial or deep?
2. Character or Quality. This calls for specific descriptive terms such as burning, sharp, dull, aching,
gnawing, throbbing, shooting, viselike. Use similies – does blood in the stool look like sticky tar? Does
the blood in vomitus look like coffee grounds?

3. Quantity or Severity. Attempt to quantify the sign and symptom such as “profuse menstrual flow
soaking five pads per hour.” The symptom of pain is difficult to quantify because of individual
interpretation. What one person may identify as “terrible pain”, another may describe as “not too bad”.
With pain, avoid adjectives and ask how it affects daily activities. Then the person might say, “I was so
sick I was doubled up and couldn’t move,” or “I was able to go work, but then I came home and went
to bed.”
4. Timing (Onset, Duration, Frequency). When did the symptom first appear? Give the specific date and
time, or sate specifically how long ago the symptom started prior to arrival (PTA). “The pain started
yesterday” will not mean much when you return to read the record in the future. The report must
include questions such as: How long did the symptom last (duration)? Was it steady (constant) or did it
come and go during that time (intermittent)? Did it resolve completely and reappear days or weeks later
(cycle of remission and exacerbation)?
5. Setting. Where the person or what was the person doing when the symptom started? What brings it on?
For example, “Did you notice the chest pain after shoveling snow, or did the pain start by itself?”
6. Aggravating or Relieving Factors. What makes the pain worse? Is it aggravated by weather, activity,
food, medication, standing bent over, fatigue, time of day, season, and so on? What relieves it (e.g.,
rest, medication, or ice pack)? What is the effect if any treatment? Ask, “What have you tried?” or
“What seems to help?”
7. Associated Factors. Is this primary symptom associated with any others (e.g., urinary frequency and
burning associated with fever and chills)? Review the body system related to this symptom now rather
than wait for the review of systems.
8. Patient Perception. Find out the meaning of the symptom by asking how it affects daily activities.
Also ask directly, “What do you think it means?” This is crucial because it alerts you to potential
anxiety if the person thinks the symptom may be ominous.

PAST HEALTH

Past health events may have residual effects on the current health state. Also, the previous experience with
illness may give clues as to how the person responds to illness and to the significance of illness for him or her.

CHILDHOOD ILLNESSES. Measles, mumps, rubella, chicken pox, pertussis, and strep throat. Avoid
recording “usual childhood illnesses,” because an illness common in the person’s childhood (e.g., measles) may
be unusual today. Ask about serious illnesses that may have sequelae for the person in later years (e.g.,
rheumatic fever, scarlet fever, and poliomyelitis).

ACCIDENTS OR INJURIES. Auto accidents, fractures, penetrating wounds, head injuries (especially if
associated with unconsciousness), and burns.
SERIOUS OR CHRONIC ILLNESSES. Diabetes, hypertension, heart disease, sickle-cell anemia, cancer, and
seizure disorder.

HOSPITALIZATION. Cause, name of hospital, how the condition was treated, how long the person was
hospitalized and name of the physician.

OPERATIONS. Type of surgery, date, name of the surgeon, name of the hospital, and how the person
recovered.

OBSTETRIC HISTORY. Number of pregnancies (gravidity), number of deliveries in which the fetus reached
full term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (abortions), and
number of children living (living). This is recorded: Grav
______Term______Preterm______Ab_____Living_____. For each complete pregnancy, not the course of

pregnancy; labor and delivery; sex, weight, and condition of each infant; and postpartum course. For any
incomplete pregnancy, record the duration and whether the pregnancy resulted in spontaneous (S), or induced (I)
abortion.

IMMUNIZATIONS. Measles-mumps-rubella, polio, diphtheria-pertussis-tetanus, hepatitis B, Haemophilus

influenza type b, pneumococcal vaccine. Note the date of the last tetanus immunization, last tuberculosis skin
test, and last flu shot.

LAST EXAMINATION DATE. Physical, dental, vision, hearing, electrocardiogram, chest x-ray
examinations.

ALLERGIES. Note both the allergies (medication, food, or contact agent, such as fabric or environmental
agent0 and the reaction (rash, itching, runny nose, watery eyes, difficulty breathing). With a drug, this symptom
should not be a side effect but a true allergic reaction.

CURRENT MEDICATIONS. Note all prescriptions and over-the-counter medications. Ask specifically about
vitamins, birth control pills, aspirin, and antacids, because many people do not consider these to be medications.
For each medication, note the name, dose, and schedule, and ask “how often do you take each day?” “What is it
for?” and “how long have you been taking it?”

FAMILY HISTORY-GENOGRAM

Ask about the age and health practices, the age and cause of death of blood relatives, such as [parents,
grandparents, and siblings. These data may have genetic significance for the patient. Also ask about close family
members, such as spouse or children. You need to know about the person’s prolonged contact with any
communicable disease or the effect of a family member’s illness on this person.
Specifically ask for any family history of heart disease, high blood pressure, stroke, diabetes, blood
disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder,
kidney disease, and tuberculosis. Construct a family tree, or genogram, to show this information clearly and
concisely.