The Complete Health History
WRITE-UP – HEALTH HISTORY
Date _____________________
Examiner _________________
1. Biographical Data
Name _______________________________________________Phone ____________________
Address _______________________________________________________________________
Birth date ________________________ Birthplace ____________________________________
Age ________ Gender _________ Marital Status ________ Occupation ____________________
Race/ethnic origin ___________________________ Employer ___________________________
2. Source and Reliability
3. Reason for Seeking Care
4. Present Health or History of Present Illness
5. Past Health
General Health ___________________________________________________________________________________________
Childhood Illnesses ______________________________________________________________________________________
____________________________________________________________________________________________________________
Adult Illnesses:
a. Medical __________________________________________________________________
b. Surgical __________________________________________________________________
c. Psychiatric ________________________________________________________________
Accidents or Injuries _____________________________________________________________________________________
____________________________________________________________________________________________________________
Serious or Chronic Illnesses _____________________________________________________________________________
____________________________________________________________________________________________________________
Hospitalizations __________________________________________________________________________________________
____________________________________________________________________________________________________________
Operations _______________________________________________________________________________________________
______________________________________________________________________________
Obstetric History ________________________________________________________________
Gravida __________ Term ________________ Preterm pregnancies ______________
(# Term pregnancies)
(# Preterm pregnancies)
Ab/incomplete ________________________ Children living _____________________________
(Date delivery, length of labor, baby’s weight and sex, vaginal delivery/cesarean section, complications, baby’s
condition)
Immunizations; Types, Dates, Reactions:
__________________________________________________________________
Last examination dates and findings:
Yearly Physical examination __________________________________________
Eye______________________________________________________________
Hearing __________________________________________________________
Dental ___________________________________________________________
GYN______________________________________________________________
Screening Tests and Lab Reports _______________________________________
Allergies _____________________________________ Reaction __________________________
Current medications _____________________________________________________________
6. Family History
Specify:
Heart disease ______________________________ Allergies _____________________________
High blood pressure_________________________Asthma ______________________________
Stroke ___________________________________Obesity ______________________________
Diabetes _________________________________ Alcoholism ___________________________
Blood Disorders ___________________________ Mental Illness _________________________
Breast cancer _____________________________ Seizure disorder _______________________
Cancer (other) ____________________________ Kidney disease_________________________
Sickle cell ________________________________ Tuberculosis __________________________
Arthritis _________________________________
Construct Three Generation Genogram and Attach at End of Health History
7. Review of Systems
(Include both past health problems that have been resolved and current problems, including
date of onset.)
(Circle if present and comment below each section.)
General State of Health : Present weight (gain or loss, period of time, by diet
or other factors), fatigue, weakness or malaise, fever, chills, sweats or night
sweats
Skin: History of skin disease (eczema, psoriasis, hives), pigment or color
change, change in mole, excessive dryness or moisture, pruritus, excessive
bruising, rash, of lesion.
Hair: Recent 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.
Head: Any unusually frequent or severe headache, any head injury, dizziness
(syncope), or vertigo.
Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain,
diplopia (double vision), redness or swelling, watering or discharge, glaucoma
or cataracts.
Health Promotion: Wears glasses or contacts; last vision check or glaucoma
test; how coping with loss of vision if any.
Ears: Earaches, infection, discharge and its characteristics, tinnitus, or vertigo.
Health Promotion: Hearing loss, hearing aid use, how loss affects daily life,
Any exposure to environmental noise, method of cleaning ears.
Nose and Sinuses: Discharge and its characteristics, any unusually frequent or
sever 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, lesion in mouth or tongue, dysphagia, hoarseness or voice change,
tonsillectomy, altered taste.
Health Promotion: Pattern of daily dental care, use of prostheses (dentures,
bridge) and last dental checkup.
Neck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes,
goiter.
Breast: Pain, lump, nipple discharge, rash, history of breast disease, any
surgery on breasts.
Axilla: Tenderness, lump or swelling
Health Promotion: Performs breast self-examination, including its frequency
and method used, last mammogram and results.
Respiratory System: History of lung disease (asthma, emphysema, bronchitis,
pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy
breathing, shortness of breath, how much activity produces shortness of
breath, cough, sputum (color, amount), hemoptysis, toxin or pollution
exposure.
Health Promotion: Last chest x-ray and result
Cardiovascular System: Precordial or retrosternal pain, palpitation, cyanosis,
dyspnea on exertion (specify amount of exertion it takes to produce
dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema,
history of heart murmur, hypertension, coronary artery disease, anemia.
Health Promotion: Date of last ECG or other heart tests and results.
Peripheral Vascular System: Coldness, 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 complications, intermittent claudication, thrombophlebitis,
ulcers.
Health Promotion: If work involves long-term sitting or standing, avoid
crossing legs at the knees, wear support hose.
Gastrointestinal System: Appetite, food intolerance, dysphagia, heartburn,
indigestion, pain (associated with eating), other abdominal pain, pyrosis
(esophageal and stomach burning sensation with sour eructation), nausea
and liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency
of bowel movement, any recent change, stool characteristics, constipation or
diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula).
Health Promotion: Use of antacids or laxatives.
Urinary System: Frequency, urgency, nocturia (the number of times the
person awakens at night to urinate, recent change), dysuria, polyuria or
oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or
presence of hematuria), incontinence, history of urinary disease (kidney
disease, kidney stones, urinary tract infections, prostate), pain in flank, groin,
suprapubic region, or low back.
Health Promotion: Measures to avoid or treat urinary tract infections, use
of Kegel exercises after childbirth.
Male Genital System: Penis or testicular pain, sores or lesions, penile
discharge, lumps, hernia.
Health Promotion: Perform testicular self-examination? How frequently?
Female Genital System: Menstrual history (age at menarche, last menstrual
period, cycle and duration, any amenorrhea or menorrhagia, premenstrual
pain or dysmenorrheal, intermenstrual spotting), vaginal itching, discharge
and its characteristics, age at menopause, menopausal signs or symptoms,
postmenopausal bleeding.
Health Promotion: Last gynecologic checkup, last Pap smear and results.
Sexual Health: Presently in a relationship involving intercourse? Are aspects
of sex satisfactory to you and partner, any dyspareunia (for female), any
changes in erection or ejaculation (for male), use of contraceptive, is
contraceptive method satisfactory? Use of condoms, how frequently? Aware
of any contact with partner who has sexually transmitted disease (gonorrhea,
herpes, Chlamydia, venereal warts, HIV/AIDES, syphilis)?
Musculoskeletal System: History of arthritis or gout. In the joints: pain,
stiffness, swelling (location, migratory nature), deformity, limitation of
motion, noise with joint motion. In the muscles: any pain, cramps, weakness,
gait problems or problems with coordinated activities. In the back: any pain
(location and radiation to extremities) stiffness, limitation of motion, or
history of back pain or disc disease.
Health Promotion: How much walking per day. What effect of limited
range of motion on daily activities, such as on grooming, feeding, toileting,
dressing? Any mobility aids used.
Neurologic System: History 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 or distant, disorientation). In mental
status: any nervousness, mood change, depression, or any history of mental
health dysfunction or hallucinations.
Hematologic System: Bleeding tendency of skin or mucous membranes,
excessive bruising, lymph node swelling, exposure to toxic agents or
radiation, blood transfusion and reactions.
Endocrine System: History of diabetes or diabetic symptoms (polyuria,
polydipsia, polyphagia), history of thyroid disease, intolerance to heat or cold,
change in skin pigmentation or texture, excessive sweating, relationship
between appetite and weight, abnormal hair distribution, nervousness,
tremors, and need for hormone therapy.
FUNCTIONAL ASSESSMENT (Including Activities of Daily Living)
Self-Esteem, Self Concept: Education (last grade completed, other significant training) _______________________
_____________________________________________________________________________________________
Financial status (income adequate for lifestyle and/or health concerns) ___________________________________
_____________________________________________________________________________________________
Value-belief system (religious practices and perception of personal strengths) ______________________________
_____________________________________________________________________________________________
Self-care behaviors _____________________________________________________________________________
_____________________________________________________________________________________________
Activity/Exercise: Daily profile, usual pattern of a typical day ____________________________________________
_____________________________________________________________________________________________
Independent or needs assistance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer,
walking, standing, climbing stairs __________________________________________________________________
_____________________________________________________________________________________________
Leisure activities _______________________________________________________________________________
_____________________________________________________________________________________________
Exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring body’s
response to exercise) ____________________________________________________________________________
_____________________________________________________________________________________________
Other self-care behaviors ________________________________________________________________________
Sleep/Rest: Sleep patterns, daytime naps, any sleep aids used ___________________________________________
_____________________________________________________________________________________________
Other self-care behavior _________________________________________________________________________
Nutrition/Elimination: Record 24-hour diet recall _____________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Is this menu pattern typical of most days? ___________________________________________________________
Who buys food? ________________________________ Who prepares food? _____________________________
Finances adequatefor food? _____________________________________________________________________
Who is present at mealtimes? _____________________________________________________________________
Other self-care behaviors ________________________________________________________________________
Interpersonal Relationships/Resources: Describe own role in family _____________________________________
How getting along with family, friends, co-workers, classmates __________________________________________
_____________________________________________________________________________________________
Get support with a problem from __________________________________________________________________
How much daily time spent alone? _________________________________________________________________
Is this pleasurable of isolating? ____________________________________________________________________
Other self-care behaviors ________________________________________________________________________
Coping and Stress Management: Describe stresses in life now: __________________________________________
_____________________________________________________________________________________
Change in past year ____________________________________________________________________
Methods used to relieve stress ___________________________________________________________
Are these methods helpful? ______________________________________________________________
Personal Habits: Daily intake caffeine (coffee, tea, colas) ______________________________________
_____________________________________________________________________________________
Smoke cigarettes? ____________________________________ Number packs per day _____________
Daily use for how many years ___________________________ Age started ______________________
Ever tried to quit? ___________________________________How did it go? ____________________
Drink alcohol? ______________________________________ Date last alcohol use ________________
Amount of alcohol that episode __________________________________________________________
Out of last 30 days, on how many days had alcohol? __________________________________________
Any use of street drugs? _________________________________________________________________
Marijuana?___________________ Cocaine?___________________ Crack cocaine? ______________
Amphetamines?______________ Barbiturates? _________________ LSD? _____________________
Heroin?______________________ Other? _________________________________________________
Ever been in treatment for drugs or alcohol?
Environment/Hazards: Housing and neighborhood (type of structure, live alone, know neighbors)_____
_____________________________________________________________________________________
Safety of area _________________________________________________________________________
Adequate heat and utilities ______________________________________________________________
Access to transportation ________________________________________________________________
Involvement in community services _______________________________________________________
Hazards at workplace or home ___________________________________________________________
Use of seat belts _______________________________________________________________________
Travel to or residence in other countries ____________________________________________________
Military service in other countries _________________________________________________________
Self-care behaviors _____________________________________________________________________
Intimate Partner Violence: How are things at home? Do you feel safe?___________________________
_____________________________________________________________________________________
Ever been emotionally or physically abused by your partner or someone important to you? ___________
Ever been hit, slapped, kicked, pushed or shoved, or otherwise physically hurt by your partner or expartner? _____________________________________________________________________________
Partner ever force you into having sex? _____________________________________________________
Are you afraid of your partner or ex-partner? ________________________________________________
Occupational Health: Please describe your job ______________________________________________
Work with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)? ______________
_____________________________________________________________________________________
Any equipment at work designed to reduce your exposure? ____________________________________
Any work programs designed to monitor your exposure? ______________________________________
Any health problems that you think are related to your job? ____________________________________
What do you like or dislike about your job? _________________________________________________
Perception of Own Health: How do you define health?
View of own health now ________________________________________________________________
What are your concerns? _______________________________________________________________
What do you expect will happen to your health in future? _____________________________________
____________________________________________________________________________________
Your health goals ______________________________________________________________________
Your expectation of nurses, physicians _____________________________________________________
_____________________________________________________________________________________
References: Jarvis, C. (2012). Physical examination & health assessment student laboratory manual
(6thed.). St. Louis: Saunders-Elsevier ; Hogan, B. , Palm, M., & Bickley, L. (2012). Bates’ nursing guide to
physical examination and history taking. Philadelphia: Wolters Kluwer.