WRITE – UP HEALTH HISTORY
Date__________________________
Examiner _____________________
I. BIOGRAPHICAL DATA
Name ________________________________ Phone ____________________________________
Address _________________________________________________________________________
Birth date __________________________________Birthplace ____________________________
Age ________ Gender ________ Marital Status_________ Occupation _____________________
Race/Ethnic Origin ____________________ Employer ___________________________________
II. SOURCE AND RELIABILITY
III. REASON FOR SEEKING CARE (CC): Main reason for consulting health professional. State
briefly in client’s own words (when possible). State onset and duration briefly.
IV. PRESENT HEALTH OF HISTORY OF PRESENT ILLNESS:
Needs to be well organized and sequentially developed. Clear, chronological account of problem
for which client is seeking care. Should include:
O.
Onset: Exactly when did it start? When did you first notice it?
P.
Provocative or Palliative: What brings it on? What where you doing when you first
noticed it? What makes it better? Worse?
Q.
Quality or Quantity: How does it look, feel, or 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: Is it constant or does it come or go?
Duration- How long did it last?
Frequency- How often does it occur?
U.
Understanding patients perception of the problem
What do you think it means?
ADD. Associated Factors, Significant negatives: Is this primary symptom associated with any
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others? Review ROS r/t this symptom, Medication regimen (including alcohol and tobacco use).
V. PAST HEALTH
Describe General Health ___________________________________________________________
Childhood Illnesses ________________________________________________________________
Accidents or Injuries (include age) ___________________________________________________
Serious or Chronic Illnesses (include age) _____________________________________________
Hospitalizations (what for? Location) ________________________________________________
Operations (name, procedure, age) ___________________________________________________
Obstetric Hx: Gravida (# Pregnancies) _____Term (# Term Pregnancies) ______Preterm (# preterm
pregnancies)___________
Ab/Incomplete (#Abortions/Miscarriages) ________Children Living __________________
Course of Pregnancy ______________________________________________________________
(date of delivery, length of pregnancy, length of labor, baby's weight and sex, vaginal
delivery/cesarean section, complications, baby's condition).
Immunizations __________________________________________________________________
Last Examination date ___________________________________________________________
Allergies ____________________________ Reaction __________________________________
Current Medications: (List all prescribed and non-prescribed drugs including Name, Dose, Route,
Frequency)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
VI. FAMILY HISTORY – Specific
Heart Disease___________________________
Allergies __________________________
High Blood Pressure _____________________
Asthma ___________________________
Stroke _________________________________
Obesity ___________________________
Diabetes ________________________________
Alcoholism or drug addiction __________
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Blood Disorders _________________________
Mental Illness ________________________
Breast/Ovarian/Colon Cancer ________________
Suicide ______________________________
Cancer (other) ____________________________
Seizure Disorder ______________________
Sickle Cell _______________________________
Kidney Disease _______________________
Arthritis _________________________________
Tuberculosis __________________________
Construct Genogram Below
VII. REVIEW OF SYSTEMS (Document both past health problems that have been resolved and
current problems including date of onset.) :Describe positive (P/S or P/C or P/R) items. List all
pertinent negative items, e.g., P/D any unusually frequent or severe headache, any head injury,
syncope, or vertigo under HEAD.
1. General Overall Health State: Present weight (gain or loss, period of time, by diet or other factors),
fatigue, weakness or malaise, fever, chills, sweats or night sweats.
2. Skin: History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole,
excessive dryness or moisture, pruritus, excessive bruising, rash, or lesion.
3. Hair: Recent loss, change in texture.
4. Nails: Change in shape, color, or brittleness.
Health Promotion: Amount of sun exposure, method of self-care for skin and hair.
5. Head: Any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigo.
6. 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
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with loss of vision if any.
7. Ears: Earaches, infections, 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.
8. Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus
pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell.
9. 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
checkups.
10. Neck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter.
11. Breast: Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts.
Axilla: Tenderness, lump or swelling, rash.
Health Promotion: Performs breast self-examination, including its frequency and method used,
last mammogram and results.
12. 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 examination.
13. 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.
14. 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.
15. 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 vomiting (character), vomiting blood, history of abdominal disease (ulcer,
liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any
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recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal
conditions, hemorrhoids, fistula).
Health Promotion: Use of antacids or laxatives.
16. 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, prostrate); pain in flank, groin, suprapubic region, or low back.
Health Promotion: Measures to avoid or treat urinary tract infections; Kegel exercises after
childbirth.
17. Male Genital System: Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia.
Health Promotion: Perform testicular self-examination? How frequently?
18. Female Genital System: Menstrual history (age at menarche, last menstrual period, cycle and
duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, inter-menstrual
spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or
symptoms, post- menopausal bleeding.
Health Promotion: Last gynecologic checkup, last Pap smear and results.
19. 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
contraceptives, is contraceptive method satisfactory? Use of condoms, how frequently? Aware of any
contact with partner who has sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal
warts, HIV/AIDS, syphilis)?
Health Promotion: Prevention of STI’s? STI checkup as needed?
20. 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
disk disease.
Health Promotion: How much walking per day? What is the effect of limited range of motion on
daily activities, such as on grooming, feeding, toileting, dressing? Any mobility aids used?
21. Neurologic System: History of seizure disorder, stroke, fainting, blackouts. In motor function:
weakness, tic or tremor, paralysis, 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.
22. Hematologic System: Bleeding tendency of skin or mucous membranes, excessive bruising, lymph
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node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.
23. 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,
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 ADL’s, 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:_____________________________________________________________
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Sleep/Rest: Sleep patterns, daytime naps, any sleep aids used:
___________________________________________________________________________________
___________________________________________________________________________________
Other self-care behaviors:______________________________________________________________
Nutrition/Elimination: Record 24 hour diet recall
___________________________________________________________________________________
___________________________________________________________________________________
Is this menu pattern typical of most days? _________________________________________________
Who buys food? _____________________________Who prepares food?________________________
Finances adequate for food? ___________________________________________________________
Who is present at mealtimes? __________________________________________________________
Other self-care behaviors _____________________________________________________________
Interpersonal Relationships/Resources: Describe own role in family__________________________
How is getting along with family, friends, co-workers, classmates ____________________________
Get support with a problem from _______________________________________________________
How much daily time spent alone? ______________________________________________________
Is this pleasurable or 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? ____________________________________________________________
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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 during that episode____________________________________________________
Out of last 30 days, on how many days had alcohol? ________________________________________
Ever had a drinking problem? __________________________________________________________
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 seatbelts______________________________________________________________________
Travel to or residence in other countries __________________________________________________
Military service in other countries ______________________________________________________
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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? ___________________________________
Are 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 expectations of nurses, physicians?
_______________________________________________________________________________
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