HEALTH HISTORY
I.
DATE AND TIME OF INTERVIEW
II.
SOURCE AND RELIABILITY
III.
GENERAL INFORMATION (Demographic Data) (Identification Data)
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
IV.
Name
Address
Telephone
Age
Marital Status
Occupation
Religion
Ethnicity
Billing Information
Source of Referral
Date of Last Exam
Other: Can include current and/or previous involvement in health care system;
i.e., attending physician, clinic/HMO involvement, Visiting Nurse, Home Care
Agency, etc.
CHIEF COMPLAINT (CC): Main reason for consulting health professional. State
briefly in client’s own words (when possible). State onset and duration briefly.
V.
HISTORY OF PRESENT ILLNESS (HPI): (Narrative format)
Needs to be well organized and sequentially developed. Clear, chronological
account of problem for which client is seeking care. Should include:
A.
B.
C.
D.
E.
F.
G.
H.
I.
Time of onset of complaint (problem)
Character of complaint (problem)
Mode of onset
Location
Relationship to other symptoms
Exacerbations and remissions
Effect of past treatment
Relevant diagnostic testing done
Significant negatives
Note: All principal symptoms should be described in terms of their 1) location, 2)
quality, 3) quantity or severity, 4) timing (i.e., onset, duration, frequency), 5) setting, 6 factors
that aggravate or relieve symptoms, and 7) associated manifestations.
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V.
PAST HISTORY
A. GENERAL STATE OF HEALTH
This is often cited briefly in the opening statement of the HPI
B. CHILDHOOD ILLNESSES, IMMUNIZATIONS, COMMUNICABLE
DISEASES
List disease separately and chronological
Cite age of occurrence (if known)
Ask specifically rheumatic fever, serology for rubella, when last boosters were given,
History of polio and any residual disability, exposure to communicable diseases,
travel, etc.
Note: Communicable disease and travel history are not usually addressed directly in
this section which is often limited to Childhood illness and immunizations. With
Current lifestyles their inclusion here may be warranted.
C.
MEDICAL ILLNESSES (HISTORY)
List medical illnesses (cite specific detail if indicated)
List previous (medical) hospitalizations chronologically (date, place, discharge
diagnosis (es) when known, etc.
D.
SURGICAL HISTORY
List chronologically (date, place, procedure done, etc. )
Give specific details of surgery and post-op period (if indicated)
E.
INJURIES (ACCIDENTS) (TRAUMA)
List only those that are significant.
Cite type of injury, date, treatment, residual effects, etc.
F.
PSYCHIATRIC ILLNESSES
G.
ALLERGIES
List allergies to food, pollen, drugs, chemicals, biological.
Describe how allergy is manifested (Reaction), treatment history, etc.
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H.
CURRENT MEDICATIONS AND DOSAGES
Name, Dose, Route, Frequency
List all prescribed and non-prescribed drugs
I.
DIET AND NURTRITION
J.
REST AND SLEEP PATTERN
K.
HABITS
1.
2.
3.
4.
5.
Smoking (tobacco)
Drinking (caffeine, ethanol, other)
Use of drugs (prescribed, non-prescribed, drugs of abuse)
Exercise
Hobbies
VII. FAMILY HISTORY (Genogram required) **
A. Age and health, or age and cause of death, of each immediate family member (ie,
parents, siblings, spouse, children). Information re: grandparents and
grandchildren also sometimes indicated.
This information is to diagrammed
B. Occurrence within the family of any of the following is cited. Relationship to the
patient is signified.
Hypertension, Stroke, Heart Disease, Diabetes, Kidney Disease, Cancer, Anemia,
Bleeding Tendency, Tuberculosis, Arthritis, Peptic Ulcer, Hyperlipidemia, Headaches,
Mental Illness, or symptoms like those of the patient.
VII.
PSYCHOSOCIAL HISTORY (PERSONAL AND SOCIAL HISTORY)
Outline or narrative format
A. Cultural and Social
1. Nationality
2. Religious affiliation and or preferential practices
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3. Dominant language used. How well does the client understand and use the
English language?
4. Cultural Values. Influence of culture on client’s view of family, male and
female roles, childrearing practices, use of resources, health and illness
behavior.
5. Socioeconomic background (influence of social and economic status on
patterns of socialization, family structure, health beliefs, etc.
6. Relationships with significant others and family constellation
7. Membership in professional and social organizations
What meaning do these groups have for the client?
B. Marital and Sexual History
Normal patterns of interaction; feelings toward sexuality; satisfaction with sexual
relationships; patterns of closeness, warmth, and companionship with others;
changes in sexual response since any change in life style; etc.
C. Educational History
D. Occupational History
Occupation, pattern of employment, occupational hazards and exposure to
Irritants, any work related disability, etc.
E. Typical Day
F. Developmental tasks of the individual (extent met)
G. Client’s Perception and Satisfaction with his health status.
H. Family’s perception of client’s health problems and its impact on the
family
I. Environmental factors
J. Client’s Health Goals
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IX.
REVIEW OF SYSTEMS
1. GENERAL: weight change, weakness, fatigue, fever, chills, night sweats, sleeping
Habits
2. INTEGUMENT (SKIN): rashes, sweating, dryness, color change in hair or nails,
Itching, lumps, bleeding tendency/bruising
3. HEAD (CENTRAL NERVOUS SYSTEM): headache, head injury, syncope,
seizures, vertigo, paralysis/paresis, tremor, ataxia, dysesthesias
4. EYES:
acuity, glasses/contact lenses, prosthetics, last eye exam, pain, redness,
excessive tearing, double visison, blurred vision, cataracts, glaucoma
5. EARS:
pain, hearing loss, deafness, infection, discharge, tinnitus, ruptured
Tympanic membrane
6. NOSE AND SINUSES: nasal stuffiness, frequent colds, sinus trouble, epistaxis
olfactory changes, deviated septum, hay fever
7. MOUTH AND THROAT: condition of teeth and gums (caries, extractions,
dentures, caps, bleeding gums, pyorrhea), difficulty chewing, date of last
dental exam, sore tongue, taste changes, frequent sore throats,
coarseness, difficulty swallowing (dysphagia)
8. NECK:
lumps in neck, “swollen glands”, goiter (thyroid problem), pain in neck
9. BREASTS: skin changes, pain, nipple changes,lumps (masses),fibrocystic disease,
breast cancer history, knowledge of self-exam
10. RESPIRATORY: cough, sputum (color and quantity), hemoptysis, wheezing,
dyspnea, pain on respiration, frequent respiratory infections, asthma,
bronchitis, emphysema, pneumonia, tuberculosis, exposure to
tuberculosis, tuberculin test (date and result)
11. CARDIOVASCULAR: chest pain, typical angina pectoris, palpitations, exertional,
dyspnea, orthopnea, paroxysmal nocturnal dyspnea, murmur, rheumatic
fever, heart disease, past EKG or other heart tests
12. GASTROINTESTINAL: trouble swallowing (dysphagia), appetite, dietary habits,
food intolerance, heartburn (indigestion), abdominal pain, nausea,
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13.
14.
15.
16.
vomiting, vomiting blood (hematemesis), excessive belching or flatus
(passing gas), change in bowel habits, diarrhea, constipation, frequency of
bowel movements, hemorrhoids, rectal bleeding, black tarry stools
(melana), mucous in stool, hernia, liver or gallbladder disease (hepatitis,
jaundice, stones), pancreatitis, use of laxatives or antacids
URINARY: dysuria (painful urination), frequency, urgency, hesitancy, polyuria,
incontinence, decreased urinary stream, nocturia, urinary infections,
stones (calculi), prostate problems
REPRODUCTIVE:
Male: penile discharge or lesion, history of VD and its
treatment, serology, hernias, testicular pain,
swelling, or masses, infertility, impotence, libido,
sexual problems
Female: Gynecologic History: age of menarche________,
LMP___/___/___, age of menopause ______,
Abnormal masses, amount of bleeding (menstrual,
intermenstrual, postcoital, postmenopausal),
leukorrhea, pruritis, history of VD and its treatment,
serology, libido, sexual difficulties, frequency of
intercourse, Last PAP:___/__/__,results_____,
Obstetric History: pregnancies________,
abortions_______,(spontaneous and induced), full
term deliveries_______, complications,
contraceptive methods__________________
MUSCULOSKELETAL: joint pain, stiffness, swelling (edema), heat, redness
(rubor), deformity, stiffness (limited motion/activity), myalgias (muscle
pains or cramps), weakness, bone fracture, arthritis, gout, backache,
sciatica
ENDOCRINE: thyroid disease, goiter, hear or cold intolerance, change in voice,
excessive sweating, diabetes, polyuria, polyphagia, polydipsia,
(i.e.,excessive urination, hunger,thirst), gynecomastia, hirsutism
17. HEMATOLOGIC (HEMATOPOIETIC): anemia, abnormal bleeding (easy bruising
or bleeding), swollen glands (adenopathy), past transfusion and possible
reactions
18. PSYCHIATRIC (EMOTIONAL STATUS): nervousness, hyperventilation, tension,
mood, depression, insomnia, nightmares, memory loss, phobias
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