Health History

A response is required for EACH item in EACH category.
See examples of what I am looking for in the Health History.

Copy this document& record your responses in a text document (e.g.: Word or WordPerfect). That way you can just add the information  without retyping the entire document. Please reformat and delete things as appropriate (such as in the review of systems - delete the opposite sex when discussing reproductive system).

Name: (Initials only)                      Birthdate                       Sex
Address (general area)                  Highest grade completed
Place of birth                                 Marital status
Religion                                         Language spoken

1. Chief complaint - "client’s own words" (1 point)
   
2. Present Illness: clear, chronological details of chief complaint and reasons for seeking care. Symptoms are to be specified as to type, location, severity, duration, influencing factors and associated symptoms. (1)
   
3. Past Medical History: detail previous health and illnesses
   1. General health status (1)
   2. Pertinent childhood illness: evaluate for mumps, chicken pox, rubella, rubeola, scarlet fever, diphtheria, rheumatic fever, polio, frequent ear or strept infections, and year they had this. (1)
   3. Immunization status: give exact/approximate dates. Be sure to note tetanus, polio, rubella, small pox, mumps, TB testing, diphtheria, pertussis, hepatitis, pneumonia. (1)
   4. Adult illnesses: inquire about problems, which required medication or bedrest. (1)
   5. Surgical history: date, place, procedure (1)
   6. Injuries and accidents: year and if lost consciousness (1)
   7. Other hospitalizations (1)
   8. Psychiatric history (1)
   9. Allergies : specify manifestations- evaluate animals, food, medications, plants, pollen, dust, mold, chemicals (1)
   10. Current medications: amount and frequency
       1. Prescriptions (1)
       2. Over the counter - OTC (1)
       3. Street (1)
   11. Military history: self & family of origin
       1. Place (1)
       2. Exposures (1)

   L.  Recent travel - last two years - out of local area of residence (1)

   1. Family history
      1. List family members - include grandparents, parents, aunts and uncles, siblings, spouse and children.  (2)
      2. Social support - describe all the people the client has as support system, include church, work, friends, family, neighbors. Who is the client closest to? (1)
      3. Occurrence in family of arthritis, diabetes, hypertension, stroke, hearing problems, heart disease, allergies, kidney problems, seizures, headaches, tuberculosis, anemia, cancer, mental illness, congenital defects, rheumatic fever, alcoholism, symptoms that resemble those of client. You can put this in the list under (a).  (2)
   1. Personal
      1. Hours of sleep - is it undisturbed (1)
      2. Usual daily schedule - hourly account (1)
      3. Habits: smoking, alcohol, other drugs, caffeine (1)
      4. Modes of relaxation: exercise, hobbies (1)
      5. Diet
         1. Diet: regular, special - type (0.5)
         2. 24 hour intake: Make a table like the one below (1)
            

            Meal	Kind of food	Amount
            Breakfast
            Lunch
            Dinner
            Snacks

         
         c. Evaluation of intake: (1)
         

         	Child	Teen	Adult	Pregnant	Lactating	CLIENT INTAKE
         Milk	3	4	2	4	4
         Meat	2	2	2	3	2
         Fruit/veg	5	5	5	5	5
         Bread/cereal	4	4	4	4	4

4. Estimated level of nutritional intake: (1) Is diet adequate in  calories, protein, carbohydrates fat, vitamin C, vitamin A, calcium and iron? Does the client get too much of any category?

e. Food likes (0.5)
f.  Food dislikes (0.5)
g.  Food restrictions (0.5)

6. Environmental hazards to which exposed at home, work or community

a. Community: evaluate pollution, police protection,  overcrowding, availability of stores, excess noise (0.5)
b. Home: evaluate adequacy of space (persons/ room), adequacy of toilet facilities, adequacy of heat and cooling, danger of falls (stairs, throw rugs, etc.), pest control measures, danger of fires (alarms in place) (0.5)
c. Work: evaluate air pollution, noise pollution, dangerous machinery, stress, heavy lifting (0.5)

7. Occupational history:

a. Make a table with the following headings:
     Jobs held, Position, Year, Hazards (1.0)

b. Job satisfaction (0.5)

8. Economic status and resources

a. Source (1)
b. Adequacy (1)
c. Impact of major illness on economic status. Ask the client what would happen if he/she had a major illness? Does the person have adequate support and financial resources? (1)

9. Usual source of health care (1)
10. Emergency plan: burglary, fire, medical emergency (1)
11. Climate: specific problems - isolation, pollution, humidity (1)

IV. Psychosocial

1. Sex
   1. Genetically linked sex problems (1)
   2. Formation of concept of femininity and masculinity: what is their concept and who did they learn the role from. Remember everyone has a concept of both masculinity and feminity - ask about both. (1)
2. Marital status
   1. Stresses of role (1)
   2. Ability to maintain long-term relationship with either sex.  Provide an example of one of the client's long term relationships  (1)
3. Race and culture
   1. Cultural attitude toward health: how they view health (1)
   2. Predisposition to hereditary diseases (1)
4. Religious affiliation
   1. Treatments or procedures prohibited (1)
   2. Rituals held for weddings, childbirth, death (1)
5. Major stressors (1)
6. Relationship with family and significant other
   1. Frequency and quality of contacts with parents and siblings (1)
   2. Person with whom lives (1)
   3. Recent family crisis (1)
7. Client's self-concept and outlook for future (1)
   1. Life goals (1)
   2. Strengths (1)
   3. Limitations (1)
8. Developmental tasks achieved - those achieved and those working toward for the age range (2)

V. Review of systems: review each item in each category. Mention each item, whether the client has the problem or denied having the problem.  

1. General: usual weight, height, recent weight change, weakness, fatigue, fever (1)
2. Skin: rashes, lumps, itching, dryness, color change, changes in hair or nails, biopsies or other tests, lice, ticks, scabies, changes in moles (color, size, shape, use of sunscreen (1)
3. Head: headache, head injury, tests and results (1)
4. Eyes: vision, glasses or contact lenses, date of last eye examination & results, other tests, pain, redness, excessive tearing, double vision, glaucoma, cataracts (1)
5. Ears: hearing, tinnitus, vertigo, earaches, infection, discharge (1)
6. Nose and sinuses: frequent colds, nasal stuffiness, hay fever, nosebleeds (1)
7. Mouth and throat: condition of teeth and gums, bleeding gums, last dental examination & results, sore tongue, frequent sore throats, hoarseness (1)
8. Neck: lumps in neck, swollen "glands", goiter, pain in neck (1)
9. Breasts: lumps, pain, nipple discharge, self-examination and frequency, timing of exam with menses, last exam by health care provider and results, date of last mammogram (if appropriate) & results (1)
10. Respiratory: cough, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, shortness of breath, sputum (color, quantity), hemoptysis, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy, date of last tuberculin test & results, last chest x-ray & results, other tests with results (1)
11. Cardiac: heart trouble, high blood pressure, rheumatic fever, heart murmurs, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, chest pain, palpitations, date of last electrocardiogram & results, other tests with results (1)
12. Gastrointestinal: trouble swallowing, heartburn and treatments, appetite, nausea, vomiting, vomiting blood, indigestion, frequency of bowel movements, change in bowel habits, rectal bleeding, black tarry stools, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or passing gas, hemorrhoids, jaundice, liver or gall bladder trouble, hepatitis, laxative use (frequency & type) (1)
13. Urinary: usual bladder habits, change in bladder habits, frequency of urination, polyuria, nocturia, dysuria, hematuria, urgency, hesitancy, incontinence, urinary infections, stones, last urinalysis and results, other tests and results (1)
14. Genitoreproductive

    Male: discharge from or sores on penis, history of sexually transmitted disease and its treatment, hernias, testicular pain or masses, frequency of intercourse, libido, sexual difficulties, testicular self-examination, birth control methods, tests and results (1)

    Female: age at menarche; regularity, frequency and duration of periods; amount of bleeding, bleeding between periods or after intercourse, last menstrual period; dysmenorrhea, age of menopause, menopausal symptoms, post-menopausal bleeding, discharge, itching, sexually transmitted disease and its treatment, last Pap smear & results, number of pregnancies, number of deliveries, number of abortions (spontaneous or induced), complications of pregnancy, birth control methods, frequency of intercourse, libido, sexual difficulties (1)

15. Musculoskeletal: joint pains or stiffness, arthritis, gout, backache, If present, describe location and symptoms (for example, swelling, redness, pain, stiffness, weakness, limitation of motion or activity). Muscle pains or cramps. Tests and results. (1)
16. Peripheral vascular: intermittent claudication, cramps, varicose veins, thrombophlebitis, tests and results. (1)
17. Neurological: fainting, blackouts, seizures, paralysis, local weakness, numbness, tingling, tremors, memory problems, tests and results.  (1)
18. Psychiatric: nervousness, tension, moodiness, depression (1)
19. Endocrine: thyroid trouble, heat or cold intolerance, excessive sweating, diabetes; excessive thirst, hunger or urination; tests with results  (1)
20. Hematologic: anemia, easy bruising or bleeding, date and number of past transfusions and possible reactions (1)

VI. Reliability of informant (1) – how do you know client is telling the truth (client behaviors)?
VII. Client strengths (10) - ones you identify from the data you have gathered
VIII. Interventions list: (10)

After you have taken the health history on your client, you will want to identify some health promotional strategies to recommend to your client. When determining the types of interventions that would be appropriate for recommendation in relation to your client you will want to review the 5 areas (rest & sleep, exercise, nutrition, safety and activities of daily living) to see if there are any deficiencies that are evident or which could become an area of health risk for your client. Below are suggested areas for health promotional interventions (you may choose other areas).

Suggested areas for Health Promotional Interventions: