Health History

Definition:
• Data collected about a patient’s
level of wellness, changes in life
patterns, sociocultural role, &
mental and emotional reactions to
illness.
• A structured interview
designed to collect specific
data & to obtain a detailed
health record of a client.
• It is a systematic collection of
subjective & objective data ordering
in a step to step process in culcating
detailed information in determining
client’s history health status,
functional status & coping pattern.
 Purposes:
1. To elicit information about all variables that
may affect the client’s status.
2. To obtain data that helps the nurse understand
and appreciate client’s life experiences.
3. To initiate a non judgmental trusting
interpersonal relationship with the
client.
 8 Compartments:
1. Biographic data
2. Reason for seeking health care
3. History of present illness
4. Past medical history
5. Family History
6. Review of systems
7. Lifestyle & health practices
8. Developmental history
 8 Components:
1. Biographic Data:
• Name:
• Address:
• Age:
• Sex:
• Marital status:
• Religion:
• Birthdate:
• Place of Birth:
• Ethnic Background:
• Educational level:
• Occupation:
• Provider of history ( patient or others)
• Significant others or support persons
 8 Components:
2. Reasons for seeking Health Care
reason for seeking health care
Feelings about seeking health care
2 questions:
1. “What is your major health
problem or what brought you to
the hospital or clinic?”
 8 compartments

“What is troubling you? Or “How

can I help you?”

2. “How do you feel about having to

seek health care?”
 8 compartments
3. History of Present Illness
Using the pneumonic COLDSPA
C – Character
O – Onset
L - Location
D – Duration
S – Severity
P – Pattern
A – Associated Factors
 8 compartments
4. Past Medical History
• Birth
• Childhood diseases
• Immunizations
• Allergies
• Previous health problems
• Hospitalizations
• Surgeries
 8 compartments

4. Past Medical History

• Pregnancies – births
• Previous accidents
• injuries
• Pain experiences
• emotional or psychiatric problems
 Family history

• Genetic predisposition
• Brief summary of the kinds of
health problems present in the
family.
 Review of Systems
- To draw out current health problems
from the recent past that may still
affect the client or that may be
recurring.
- Questions should be asked in terms
that the client understands but
findings may be recorded in standard
medical terminology.
 Review of Systems
• Skin, hair and Nails
• Head and neck
• Ears
• Eyes
• Mouth, Throat, Nose and Sinuses
• Thorax and lungs
• Breast
 Review of Systems
• Heart
• Abdomen
• Male/Female Genitalia
• Musculoskeletal
• Neurological
 Lifestyle & Health Practices
Includes
• nutritional habits,
• Activity & exercise patterns
• Sleep & rest patterns
• Use of meds and substances
• Self concept & self care activities
• Relationships
Lifestyle & Health Practices
• Values & belief
• Education & work
• Stress level
• Coping style
• Environment
 Lifestyle & Health Practices
Nutrition & Weight Management
• 24 hour Intake
• Food habits
• Fluid intake
• Type of fluids
• Bowel and bladder habits
Lifestyle & Health Practices
Activity level & exercise
• Inquire about regular exercise
• Assess how active the client is.
 Developmental
It helps to determine any
developmental impairments.

Erik Erickson – Psychosocial theory

 Lifestyle & Health Practices
Sleep & rest
• Sleep patterns
• Inquiries about sleep can bring out
problems such as anxiety.