The Comprehensive Health History

The Comprehensive Health HistoryThe purpose of health history is to collect subjective data what the patient says about himself or herself. The history is combined with objective data from the physical examination and laboratory studies to form the data base.The health history provides a comprehensive portrait of the patients past and present health. The components of a health history are as follows:Biographic DataReason for Seeking Care (Chief complaint of present illness)Present health or history of present illnessCurrent medicationsFamily historyReview of systemsFunctional assessment of activities of daily living (ADLs)The Health History The AdultBiographic DataNameAddress and phone numberAge and birth dateBirthplaceGenderMarital StatusRace, Ethnic OriginOccupation (usual and present an illness or disability may have prompted change in occupation)Language and communication needs (primary language and authorized representative should be recorded; if the patient does not speak English or Filipino/Tagalog, specify the language/dialect spoken (e.g. speaks Ilocano only, speaks Korean only).Source of HistoryRecord who furnishes the information (e.g. the patient, relative or friend).

Judge how reliable the information seems and how willing he or she is to communicate. What is reliable? A reliable person always givers the same answers, even when questions are rephrased or are repeated later in the interview.Note any special circumstances, such as the use of an interpreter. Examples:Patient herself, who seems reliable.Patients son, Joseph Guerrero, who seems reliable.Mrs. Cynthia Aguilar, interpreter for Anusha Motomal who does not speak Filipino or English.

Reason for Seeking Care (Chief Complaint)This is a brief spontaneous statement in the patients own words that describes the reason for the visit. It states one (possibly two) signs or symptoms and their duration.A sign is an objective abnormality that can be detected on physical examination or in laboratory studies.A symptom is a subjective sensation that the person feels from the disorder.

The chief complaint is enclosed in quotation marks to indicate the persons exact words. This is now replaced with reason for seeking care that incorporates wellness needs.Examples:Chest pain for 2 hours.Earache and fussy all night.Dizziness and ringing of the right ear.Need yearly physical examination for work.The chief complaint is not a diagnostic statement. Avoid translating it into terms of a medical diagnosis (e.g., increasing shortness of breath for four hours, not emphysema.Present Health or History of Present IllnessFor the well person, this is a short statement about general state of health.For the ill person, this is a chronological record of the reason for seeking care, from the time the symptom first started until now.Example: Please tell me all about your headache, from the time it started until the time you came to the hospital.

The final summary of any symptom should include the following eight critical characteristics:LocationQuality or Character. This calls for specific descriptive terms such as burning, sharp, dull, aching, gnawing, throbbing, shooting, viselike. Use similes Does blood in the stool look like sticky tar? Does blood in the vomitus look like coffee-grounds?Quantity or Severity. Attempt to quantify the sign and symptom, e.g., profuse menstrual flow soaking five pads per hour.Timing (Onset, Duration, Frequency).When did the symptom first appear? Or state specifically how long ago the symptom started prior to arrival.How long did the symptom last?Was it steady (constant) or did it come and go during that time (intermittent)?Setting. Where was the person or what was the person doing when the symptom started? What brings it on?Example: Did you notice the chest pain after carrying a heavy load, or did the pain start by itself?

Aggravating or Relieving Factors.What makes the pain worse?Example: Is it aggravated by weather, activity, food, medication, time of day, season and so on?What relieves it (e.g., rest, medication, ice pack)?What is the effect of treatment?Example: What have you tried? or What seems to help?

Associated Factors. Is the 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.Patients 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 the nurse to potential anxiety if the person thinks the symptoms may be ominous.

To help remember all the points, organize this question sequence into the mnemonic PQRSTU.P:Provocative or Palliative. What brings it on? What were you doing when you first notice it? What makes it better? Worse?Q:Quality or Quantity. How does it look, feel, sound? How intense/severe is it?R:Region or Radiation. Where is it? Does it spread anywhere?S:Severity Scale. How bad is it (on a scale of 1 to 10?) Is it getting better, worse, staying the same?T:Timing. Onset exactly when did it first occur? Duration how long did it last? Frequency how often does it occur?U:Understand Patients Perception of the Problem. What do you think it means?

Past Health HistoryPast health events may have residual effects on the current state of health.Previous experience with illness may give clues on how the patient responds to illness and to the significance of illness for him or her.Childhood Illnesses. Measles, mumps, rubella, chicken pox, pertussis and strep throat.Accidents or injuries. Auto accidents, fractures, head injuries, burns, falls.Serious or Chronic Illnesses. Diabetes, hypertension, heart disease, cancer, seizure disorder.Hospitalizations. 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 hospital and how the person recovered.Obstetric History. Number of pregnancies (Gravidity), number of deliveries in which the fetus reached full term, number of preterm pregnancies, number of abortions and number of children living. This is recorded: Gravida ______ Term ______ Preterm ______ Abortion ______ Living ______.Immunizations: Measles Mumps Rubella (MMR), polio, diphtheria pertussis tetanus (DPT), hepatitis B, human papilloma virus (HPV), haemophilus influenza type b (Hib), 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 (ECG), chest X-ray examinations.Allergies. Note both the allergen (medication, food, or contact agent) and the reaction (rash, itching, runny nose, watery eyes, difficulty breathing).

Current Medications (Medication Reconciliation)Note all prescription and over-the-counter (OTC) medications and herbal remedies.Ask specifically for vitamins, birth control pills, aspirin and antacids.For each medication, note the name, dose and schedule and ask, How often do you take it each day? What is it for? and How long have you been taking it?Prescribed medications may have adverse interactions with OTCs and herbal medications.This also ensures evaluation of medications taken by the patient by the physician either to continue the medication unchanged, to continue but change the dose, or to discontinue the medication.

Family HistoryAsk about the age and health or age and cause of death of blood relatives such as parents, grandparents, siblings. These data may have genetic significance for the patient.Ask about close family members such as spouse and children. If there is prolonged contact with any communicable disease (e.g., husband has pulmonary tuberculosis).Ask family history of heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease and tuberculosis.

Review of Systems (ROS)The order of the examination is from head to toe.Remember, that the health history should be limited to patient statements or subjective data factors that the person says were or were not present.

General Overall Health StatePresent weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats, or night sweats.SkinHistory of skin disease (eczema, psoriasis), change in pigmentation, texture or color, change in mole, excessive dryness, sweating, pruritus, hair growth and distribution, excessive bruising.HairRecent loss, change in texture. Nails: change in shape, color or brittleness.Health promotion: amount of sun exposure, method of self care for skin and hair.HeadAny unusually frequent or severe headache, any head injury, dizziness, vertigo, syncope.EyesDifficulty with vision (decreased activity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma, cataracts, photophobia, itching.Health Promotion: Wears glasses or contacts; last vision check or glaucoma test; and how is he/she coping with loss of vision if any.EarsEaraches, infections, discharge and its characteristics, tinnitus (ringing of the ears) or vertigo (sensation of spinning of the room or self).Health Promotion: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, and method of cleaning ears.Nose and SinusesDischarge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in the sense of smell.Mouth and ThroatMouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth and tongue, dysphagia (difficulty in swallowing), hoarseness or voice change, tonsillectomy, altered taste.Health Promotion: Pattern of daily dental care, use of prostheses (dentures, bridge) and last dental check-up.NeckPain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter.BreastPain, lump, nipple discharge, rash, history of breast disease, any surgery on the breasts.Health Promotion: Performs breast self examination (BSE), including its frequency and method used, last mammogram.AxillaTenderness, lump or swelling, rashRespiratory SystemHistory of lung diseases (asthma, emphysema, bronchitis, pneumonia, tuberculosis).Chest pain with breathingWheezing or noisy breathingShortness of breath, how much activity produces shortness of breathCough, sputum (color, amount), hemoptysis (coughing up with blood)Toxin or pollution exposureHealth Promotion: Last Chest X-ray studyCardiovascular SystemPrecordial or retrosternal painPalpitationsCyanosis (bluish discoloration of the skin)Dyspnea on exertion (e.g. shortness of breath when walking one flight of stairs, walking from chair to bath, or just talking)Orthopnea (difficulty in breathing when lying down, relieved by upright position)Paroxysmal nocturnal dyspnea (difficulty in breathing 2 to 5 hours after going to sleep during the night).Nocturia (frequent urination during the night)EdemaHistory of heart murmurHypertension, coronary artery disease, anemiaHealth promotion: Date of last ECG or other heart testsPeripheral Nervous SystemColdness, numbness and tingling, swelling of legs (time of day, activity)Discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles)Varicose veins or complicationsIntermittent claudication (leg pain on activity and exercise relieved by rest)Thrombophlebitis, ulcersHealth Promotion: Does the work involve long term sitting or standing? Avoid crossing the legs at the knees. Wear support hose.

Gastrointestinal SystemAppetite, food intoleranceDysphagia (difficulty in swallowing, heartburn, indigestion, pain associated with eatingAbdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation)Nausea and vomiting, hematemesis (vomiting blood)History of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis)Flatulence, frequency of bowel movement, stool characteristics, constipation or diarrhea, black stoolsRectal bleeding, rectal conditions (hemorrhoids, fistula)Health Promotion: Use of antacids or laxativesUrinary SystemFrequency, urgency, nocturiaDysuria, polyuria, oliguriaHesitancy or straining, narrowed streamUrine color (cloudy or presence of hematuria)Incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate enlargement)Pain in flank, groin, suprapublic region or low backHealth Promotion: Measures to avoid or treat urinary tract infections, use of Kegels exercises after childbirth

Male Genital SystemPenis or testicular painSores or lesions, penile discharge, lumps, herniaHealth Promotion: Perform testicular self examination? How frequently?Female Genital SystemMenstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea, menorrhagia, premenstrual pain or dysmenorrheal, intermenstrual spotting)Vaginal itching, discharge and its characteristicsAge at menopause, menopausal signs and symptoms, postmenopausal bleedingHealth Promotion: Last gynecologic check up and last Papanicolaou test

Musculoskeletal SystemHistory of arthritis or goutIn the joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, crepitus (noise with joint motion)In the muscles: any pain, cramps, weakness, gait problems, problems with coordinated activities.In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, history of back pain or disk disease.Health Promotion: How much walking per day? What is the effect of limited range of motion on daily activities such as grooming, feeding, toileting, dressing? Are any mobility aids used?Neurologic SystemHistory of seizure disorder, stroke, fainting blackouts.In motor function: weakness, tic or tremor, paralysis or coordination problems.In sensory function: numbness and tingling (paresthesia).In cognitive function: memory disorder (recent, distant), disorientationIn mental status: any nervousness, mood change, depression, or any history of mental health dysfunction or hallucinations.Health Promotion: Interpersonal relationships and coping patterns.Hematologic SystemBleeding tendency of skin or mucous membranes, excessive bruising Lymph node swellingExposure to toxic agents or radiationBlood transfusion and reactionsEndocrine SystemHistory of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia)History of thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy.Functional Assessment (Including Activities of Daily Living)Functional assessment measures a persons self care ability in the areas of general physical health or absence of illness. This includes the following:Activities of Daily Living (ADLs)E.g., bathing, dressing, toileting, eating, walking.Instrumental Activities of Daily Living (IADLs) or those needed for independent living.E.g., housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances.NutritionSocial Relationships and ResourcesSelf Concept and CopingHome Environment

Functional Assessment questions which should be included in the standard health history are as follows:Self esteem, Self conceptEducational attainment and trainingsFinancial status (income)Religious practices and perception of personal strengths (value belief system)

Activity/ExerciseUsual daily activities (ask: Tell me how you spend a typical day?Ability to perform ADLs: independent or needs assistance with feeding, bathing, hygiene, dressing, toileting, bed to chair transfer, walking, standing, or climbing stairs.Any use of wheelchair, prostheses or mobility aids?Leisure activities enjoyedExercise pattern (type, amount per day or week, method of monitoring the bodys response to exercise).

Sleep and RestSleep patternsDaytime napsAny sleep aids used (sleeping pills, CPAP for sleep apnea/snoring)

Nutrition/EliminationEating habits and current appetiteAsk:Who buys food and prepares food?Are your finances adequate for food?Who is present at mealtimes?Food allergies and intoleranceDaily intake of caffeine (coffee, tea, cola drinks)Usual pattern of bowel and bladder eliminationProblems with mobility or transfer in toileting, continence, use of laxatives.

Interpersonal Relationship/ResourcesSocial Role: How would you describe your role in the family? How would you say you get along with the family, friends and, and co-workers?Support Systems: To whom could you go for support with a problem at work, with your health, or a personal problem?Spiritual ResourcesFaith: Does religious faith or spirituality play an important part in your life? Do you consider yourself to be a religious or spiritual person?Influence: How does your religious faith or spirituality influence the way you think about your health or the way you care for yourself?Community: Are you a part of any religious or spiritual community or congregation?Address: Would you like me to address any religious or spiritual issues or concerns with you?Coping and Stress ManagementKinds of stresses in life, especially in the last year, any change in lifestyle or any current stress.

Personal HabitsTobacco, Alcohol, Street Drugs:Tobacco UseDo you smoke cigarettes?At what age did you start?How many packs do you smoke per day?How many years have you smoked?Have you ever tried to quit?How did it go?AlcoholDo you drink alcohol?When was your last drink of alcohol?How much did you drink that time?Out of the last 30 days, about how many days would you say that you drink alcohol?Have you ever had a drinking problem?Do you have a history of alcohol treatment?Do you have a history of family member with problem drinking?CAGE Test (Ewing, 1984) Screening Questionnaire to identify excessive or uncontrolled drinking.C ut down (Have you ever thought that you should cut down your drinking?)A nnoyed (Have you ever been annoyed by criticism of your drinking?)G uilty (Have you ever felt guilty about your drinking?)E ye Opener (Do you drink in the morning?)

If the person answers yes to two or more CAGE questions, suspect alcohol abuse.If the person answers no to drinking alcohol, ask the reason for this decision (e.g., psychosocial, legal, health, religion).Illicit/Street Drugs (Exercise great caution when asking questions about use of drugs)Ask specifically about marijuana, cocaine, amphetamines, and barbiturates.

Frequency of use and how has usage affected work or family.Environment/HazardsHousing and neighborhoodSafety of areaAdequate ventilation and utilitiesAccess to transportationInvolvement in community servicesHazards in workplace, at home

Intimate Pattern: ViolenceBegin with open ended questions.Ask: How are things at home?Do you feel safe?These are valuable initial questions, because some people may not recognize that they are in abusive situations or may be reluctant to admit it due to guilt, fear, shame or denial.If the person responds to feeling unsafe, follow up with close ended questions.

Ask:Have you ever been emotionally or physically abused by your partner or someone important to you?Within the last year, have you been hit, slapped, kicked, pushed, or shoved, or otherwise physically hurt by your partner or ex-partner?If yes, by whom?Number of times?

Does your partner ever force you into having sexual intercourse?Are you afraid of your partner or ex-partner?Occupational HealthAsk the patient to describe his or her job.Ever worked with any health hazard such as inhalants, chemicals?Wear any protective equipment?Any work programs in place that monitor exposure?Aware of any health problem now that may be related to work exposure? Perception of HealthAsk: How do you define health?How do you view your situation now?What are your concerns?What do you think will happen in the future?What are your health goals?What do you expect from nurses and physicians of other healthcare providers?

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