The Complete Health History

Grup 1 :
1. Nadia Mulya Fitri
2. Nesi Syofrita Dona
 Health History Sequence

1. Biographic data
2. Reason for seeking care
3. Present health or history of present illness
4. Past history
5. Family history
6. Review of systems
7. Functional assessment or activities of daily living (ADLs)
THE HEALTH HISTORY
1. The Adult
2. Children
3. The Adolescent
Source of History
• Record who furnishes the information-usually the person himself or
herself,although the source maybe relative ,friend,or caseworker
• Judge how reliable the information seems and how willing he or she is
to communicate. What is reliable? A reliable person always gives the
same answers,even when question are rephrased or repeated later in
the interview.
• Note any special circumstances,such as the us of an interpreter. See
sample recordings at left.
A. The Adult
Record the date and time of day of the interview

1. Biographic Data
Name :
Address :
Phone Number :
Age :
Birth Date :
Birthplace :
Gender :
Marital Status :
Race :
Ethnic origin :
Occupation :
2. Reason for seeking Care
Spontaneous statement in the person’s own words that describes the reason for
the visit. 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 abnormality that you as the examinier could detect on
physical examination or in laboratory reports.
3. Present Health or History of Present Illness
For the ill persons, this section is a chronologic record of the reason for seeking care
from the time the symtomp first started until now . Collect all the data first. Although you
want the person to respond in a narrative format without interruption from you, you final
summary of any symtomp the person has should include these eight critical characteristic :
1. Location. Ask the persons to point to the location.
2. Character or quality. This calls for specific descriptive terms such as burning
,sharp,dull,etc.
3. Quantify or Severity .Quantify the symtomp of pain using the scale shown on the right.
4. Timing . Onset, Duration, Frequency
5. Setting . Where was the person or what was the person doing when the symptom started?
6. Aggravating or Relieving Factors . What makes the pain worse
7. Associated Factors. Is this primary symptom associated with any others.
8. Patient’s Perception. Find out the meaning of the meaning of the symptom by asking
how it affects daily activities.
4. Past Health
Past health events are important because they may have residual effects on the
current health state. Also, the previous experience with illness may gives clues as to
how the person responds to illness and to the significance of illness for him or her.
• Childhood illnesses
• Accidents or injuries
• Serious or chronic illness
• Hospitalizations
• Operations
• Obstetric History
• Immuzations
• Last Examination Date
• Allergies
• Current Medications.
5. Family History
A pedigree or genogram is a graphic family tree that uses symbols to depict the
gender,relationship,and age of immediate blood relatives in at least three generations,such as
parents,grandparents,siblings.

6. Review of Systems
• General Overall Health State. Present weight,fatigue,weakness or malaise,fever,chills,sweat or
night sweats.
• Skin. History of skin disease , Pigment color change, change in mole ,pruritus,rash or lesion
• Hair. Recent loss , change in texture, change in shape
• Head. Any unsually frequent or severe headache,any head injury, dizziness or vertigo.
• Eyes. Difficulty with vision
• Ears. Eareches,infections,discharge and its characteristics,tinnitus or vertigo.
• Nose and Sinuses. Discharge and its characteristics , any unusually frequent or severe colds , sinus
pain, nasal obstruction , nosebleeds, allergies or hay fever, or change in sense of smell.
• Mouth and Throat. Mouth pain , frequent sore throat, bleeding
gums,toothache,dysphagia,tonsillectomy.
• Neck. Pain,limitation of motion,lumps or swelling,enlarged or tenders nodes,goiter.
• Breast. Pain,lump,nipplr discharge,rash,history of breast diease,any surgey on the breasts.
• Axilla. Tenderness,lump swelling,rash.
• Respiratory System. History of lungs diseases
• Cardiovascular. Precordial or retrosternal pain,cyanosis,dypsnea.
• Pheriperal Vascular. Coldness,numbness and tingling
• Gastrointestinal.Appetite,foodintolerance,dysphagia,heatburn,indigestion,pain.
• Urinary System. Frequency,urgency,nocturia
• Male Genital System. Penis or testicular pain,sores or lesions,lumps,hernia
• Female Genital System. Menstrual history, vaginal itching,discharge and its characteristics.
• Sexual Health. Sexually transmitted infection
• Musculoskeletal System. History of arthritis or gout.
• Neurologic System. History of seizure disorder, stroke,fainting,blackouts.
• Hematologic System. Bleeding tendency of skin mucous membranes , lymph node swealling, blood
transfusion and reactions.
• Endocrine System. History of diabetes
7. Functional assessment or activities of daily living (ADLs)
• Self-esteem,self concept
• Activity/Exercise
• Sleep/rest
• Nutrition/Elimination
• Interpersonal Relationships/Recources
• Spiritual Recources
• Coping and Sterss Management
• Personal Habits
• Alcohol
• Illicit or street drugs
• Environment/Hazard
• Intimate Partner Violence
• Occupational Health
B. CHILDREN
The health history is adapted to include information specific for the age and
developmental stage of the child (e.g, the mother’s health during pregnancy,labor
and delivery, and the perinatal period) (Fig. 4-3). Note that the developmental
history and nutritional data and listed as separate sections because of their
importance for current healt.
Biographic Data
Include the child’s name, nickname, address and phone number, parent’s names and
work numbers, child’s age and birth date, birthplace, gender, race, ethnic origin, and
information on other children and family members at home.
Source Of History
1. Person providing information and relation to child
2. Your impression of relability of information
3. Any special circumstances
Reason For Seeking Care
Record the parent’s spontaneous statement.
Present Health Or History Of Present Illnes
Describe any presenting symptoms or sign, using the same format as for the adult. Some
additional considerations include :
• Severity of paint
• Associated factors, such as relation to activity, eiting, and body position.
Past Healt
• Prenatal status
• Labor and delivery
• Postnatal status
• Childhood illnesses
• Serious accidents injuries
• Serious chronic illnesses
• Operations
• Operations or hospitalizations
• Immunazation
• Allergies
• Medications
Devoelopmental History
• Growth
• Milestones
• Current Development
• School-Age Child
Nutritional
Family History
Review Of Systems
• General
• Skin
• Head
• Eyes
• Ears
• Nose and sinuses
• Mouth and throat
• Neck
• Breast
• Respiratory systemas
• Cardiovascular system
• Gastrointestinal systems
• Urinary systems
• Male genital system
• Female genital systems
• Sexual health
• Muskulosketal systems
• Neurologic systems
• Hematologic systems
• Endocrine systems
Functional Assesment (Including Activities Of Daily Living)
• Interpersonal relationships
• Activity and rest
• Economic status
• Home environment
• Coping/stress management
• Habits
• Health promotion