HEALTH HISTORY GUIDE

MEDICAL/SURGICAL PATIENT

Pre-operative phase:

A. Vital Information
V/S prior to transport to OR
Name: Pre-operative diagnosis: Temp:
Age: Room number: Pulse rate:
RR:
Address: Type and name of surgery BP:
Gender: Surgeon:
Religion: Date and time of visit:
Civil Status: Anesthesiologist:
Circulating nurses: Staff : Scrub Nurses: Staff:
Student: Student:

REASON OF THE OPERATION

_____________________________________________________________

PAST HEALTH HISTORY:

Childhood Illnesses:
Positive history of mumps, chickenpox, rubella, frequent ear infections, frequent streptococcal infections
or sore throats, rheumatic fever, scarlet fever, pertussis, or asthma may have a direct link to current health
problem (e.g., history of chickenpox explains current shingles).
( Yes / No )
Indicate when, age, how long : __________________________

Hospitalizations:
Previous hospitalizations ( may have a direct link to current problem or provide clues to preexisting problems. )
(Yes/ No )
Name of hospitals : _____________________________________
Cause of hospitalization : _______________________________
dates facilitates record retrieval. __________________________
Ask about hospitalizations for both physical and psychological problems.
______________________________________________________
Surgeries: ( Yes / No)
past surgical procedures : (may rule out certain problems or explain others.)

For example, a patient with right lower quadrant pain cannot have appendicitis if his or her appendix has
been removed, but pain may be caused by adhesions.

Serious injuries:
History of serious injuries ( may relate to current problem or explain findings during physical examination
( Yes/ No)
Is yes : (fractures, head injuries with loss of consciousness, motor vehicle accidents, burns, or lacerations)
When and where:___________________________________________________

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Major/Serious or Chronic Illness:
Encourage patients with well-controlled chronic illnesses (e.g., heart disease, hypertension, diabetes,
cancer, seizures) to identify these illnesses. Otherwise they may fail to mention them if they are not
currently causing problems. Consider patient's age and ask about most prevalent diseases for her or his age
group.
( Yes/ No )
If yes: What kind of chronic illness: ____________________________________
When it started: _______________________________________________
Medication : ( Indicate the dosage , frequency, schedule) _____________

Immunizations: ( Lack of immunization may explain current problem.)

Ask if children have had the following immunizations: measles, mumps, rubella, chicken pox, hepatitis B,
diphtheria, tetanus, polio, and haemophilus influenza B (HIB). Consider patient's age and where he lives.
( Yes, No)
If yes : What vaccine : ________________________________________
When: _______________________________
Any symtopms after immunization: _______________________

Allergies: (Allergy may explain current problem.)

( Yes/ No)
If yes: causes of allergy : ______________________________________-____
type of reaction._____________________________________________
(Allergic reactions include hives, pruritus, and respiratory problems. )
(Side effects may include gastrointestinal upset, nausea, and diarrhea. )
Note: Remember that immune systems change, so patient may become sensitive to something he or she was
not allergic to before, or vice versa.
Ask if he or she has ever received penicillin: (Yes / No) If yes : reaction of the med _________________

Recent Travel: May identify exposure to health hazards and explain presenting symptoms (e.g., traveler's diarrhea)

Childbirth
_____________________________________________________________________________

Emotional, mental, or psychological health problems

Use of alcohol, tobacco, caffeine, and illicit drugs

( Yes/ No )
If yes : Since when :___________________
How may times a day:___________