Basic Health Assessment:
Obtaining and Documenting a
Comprehensive History
IMPORTANT!
• If you never touch this person, and
spend all of your time getting a good
history, you will be more likely to
come up with the correct diagnosis
than if you get a poor history and
perform a fabulous physical exam!
Identifying Data
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Date
Name
Address
Phone Number
Gender
Date of Birth
Place of Birth
Age
Ethnic/racial background
Native language
Marital status
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Primary Care Provider
Specialists
Social security number
Insurance information
Religious preference
Education
Emergency contact
Occupation
Source of referral
Source and reliability of
interviewee
• Dependents/caretaker
The Next Step
• Present illness
• History of Present Illness (HPI)
• Chief Complaint (CC)
• General Health
• Reason for Visit
ALL very similar – used interchangeably in
some settings – can be confusing.
For our Purposes 
• After the “Identifying Data”, you should
proceed with the “Chief Complaint” which
states, in the words of the care seeker, the
reason for the visit. This may be one or
more complaints or it may even just be
“I’m here for a routine checkup!”
Questions
• Tell me what brings you here today?
• Describe for me the reason you came here
today?
• What do you expect from your visit today?
• What’s troubling you today?
Next Step:
History of the Present Illness
• Once you have the “Chief Complaint”, you can
move into the “History of the Present Illness” or
HPI.
• The HPI describes information relevant to the
chief complaint(s).
• NOTE: You may not need the HPI if the person
is just coming in for an annual exam with no
complaints.
• You can think about the “Chief Complaint” as
the title of the story and the “HPI” as the story
itself .
Analysis of a Symptom: A Critical
Step in Determining a Diagnosis!!
• Define the last time the person felt
completely well. Sometimes people will
confuse the first time they became
concerned with a symptom as the onset of
that symptom.
• There may also have been other
symptoms associated with the primary
symptom that preceded it, and forgotten.
Onset -Timing
• A specific date and time is great, if you can get it!
Sometimes it’s helpful to associate symptoms with times
in a persons life – birthdays, holidays etc.
• Where the person was at the time may also help in
defining the dating.
• If possible, find out how the person felt just prior to the
symptom.
• Was the onset sudden or gradual?
• How long did this symptom last?
• How frequent is it experienced? Number of times per
hour, week, day, month?
• Again, important to narrow this down as much as
possible, go slowly – it’s that important!!
Precipitating Factors
Character of the Symptom
This is a description that best describes the
symptom, from the persons perspective. Always
try and have the person describe it first – then, if
necessary ask questions.
For example: Pain – Is it throbbing, crushing,
burning, sharp, dull, stabbing, squeezing
Another example: Shortness of breath – is it air
hunger, suffocating, gasping
Another example: Fatigue – is it complete
exhaustion, is it lack of interest, is it
incapacitating
Location
• Ask the person to identify the location(s) of
the symptom – understanding that there
may be symptoms in multiple sites or
referred.
• Identify:
• Can it be pinpointed, are there radiation
patterns, is it generalized, vague?
Quantity or Severity
• Again, try and get specific information.
For example: if it’s pain, can they describe
the severity on a scale of 1-10?
Another example: nausea – how often does
it occur?
Another example: headache – how severe is
it - are you able to function or do you have
to go to bed?
Setting
• What is the person doing and/or where is
she when she experiences this symptom?
Again, associating the symptom with some
aspect of the persons life could be helpful
–are you okay when you first get up in the
morning? Are you active or passive when
you notice it?
Factors that Aggravate or Relieve
• Sometimes people are good historians with this
info but often they are not! Don’t be surprised if
they are vague in response to this question:
what makes it better – what makes it worse?
• Common influencing factors: exercise,
excitement, meals, medication, smoking,
standing, bending over, cold or hot environment,
fatigue, time of day or season.
• A symptom diary is often the best way to get a
handle on this as well as the other elements
associated with the symptom analysis.
Efforts to Treat
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Home remedies (what and when)
Body positions (e.g. bed rest)
Over-the-counter medications
Prescription medications
Visits to other health care providers
Associated symptoms
• This refers to other symptoms that are
going on at the same time – not the
primary symptoms.
• Sometimes it’s as easy as severe
headache with associated nausea and/or
vomiting.
• Other times it’s not so obvious and may
come out later during the Review of
Systems (ROS).
Clients Perception and Impact on
Quality of Life
• In all of my years of experience, I have
found that the woman herself usually has
a strong, innate, intuitive sense of what is
causing her symptoms! Never fail to ask
this questions:
What do you think is causing this problem?
Or
Any ideas about why this is happening to
you?
Putting a Symptom Analysis
Together: One example
CC: Chest Pain
HPI: Crushing, heavy, substernal pain, radiating to
left shoulder and arm which causes the woman
to stop all activity, occurring for past three
months at about 7-10 day intervals, each attack
being only 1-2 minutes in duration. Often occurs
about an hour after meals, especially while
walking. Also brought on by severe job tension,
cold weather, large meal, climbing two flights of
steps. Relieved by stopping activity. Associated
with sweating of few minutes duration and fear
of death. Does not recall if she is short of breath.
Past History
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Components of “Past History”
Childhood Illnesses
Adult Illnesses (serious and chronic illnesses)
Psychiatric Illnesses
Accidents and Injuries
Operations
Hospitalizations
Obstetrical History
Childhood Illnesses
Ask if she has had any of the following:
Measles, mumps, rubella, chicken pox, pertussis,
strep throat, rheumatic fever, scarlet fever,
poliomyelitis, asthma.
Obtaining dates may be difficult – especially if
someone is 65 or over …..however, if the
person is 18, this could be more significant.
Also note severity and/or complications, if
indicated.
Adult Illnesses
Diabetes, hypertension, heart disease,
cancer, seizure disorders, kidney problems,
blood disorders………..basically, you are
asking about major body systems and
hoping that the person has some memory
of this, which again, is dependent on how
old they are and how many medical
illnesses they may have already
experienced!
No Need to Write a Story!
In any of these categories, I am not looking
for a narrative! In fact, just the opposite.
This is the right time and place to eliminate
verbs and write in phrases rather than
sentences 
Example: Pneumonia, right, 1966;
cholecystitis, 1969, no attacks since, no
stones.
Important to Remember
The lists of adult illness are those that have
been DIAGNOSED……..this section of the
health history is NOT for the purpose of
exploring other symptoms that the person
may have had or has presently. We’ll get
to that in the Review of Systems (ROS).
Psychiatric Illnesses
Ask if the person has ever been diagnosed
with depression, anxiety, schizophrenia,
mood disorders, personality disorders.
AGAIN, be careful here – someone may say
they have been depressed in the past,
however, if it was not diagnosed and/or
treated, it does not belong in this section!
Accidents and Injuries
As usual, you are looking for the dating and the
details of the injury. However, just as important
is the context of the accident.
For instance, if a person had an accident and fell
in her apartment – resulting in a fractured hip,
you would also want to know if she was dizzy,
did she trip over a rug, did she loose
consciousness, was it a spontaneous fracture?
IMPT: head injuries, burns, other trauma
Operations
Here is what you need to know:
What, where, when, why, and by whom.
Example: Hysterectomy, 1972 for prolonged
bleeding due to fibroids, Overlook
Hospital, NJ, no malignancy reported.
Hospitalizations
• Do NOT include anything that you have
already covered under accidents or
operations.
• Provide reason for, location, health care
provider, duration.
Example: Exacerbation of systemic lupus
with kidney involvement, Cornell Medical
Center, Dr. Zacchary, in-patient treatment
with IV steroids for 5 days.
Obstetrical History
• Complete pregnancies: number,
pregnancy course, postpartum course,
condition, weight and sex of each child
• In Complete pregnancies: duration,
termination, circumstances (including
abortions and stillbirths)
• Summary of Complications
CURRENT HEALTH STATUS
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Allergies
Immunizations
Screening Tests
Environmental
Hazards
Use of Safety
Measures
Exercise and leisure
activities
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Sleep patterns
Diet
Current Medications
Tobacco
Alcohol/Illicit drug
history
• Foreign Travel
• Sexual Activity
Allergies
• Medication, food, environmental agents. Indicate
type of reaction – rash, edema etc.
NOTE: It’s always important to clarify this- so
many people think they have allergies, when in
fact, they may just be “sensitivities” that do not
put them at serious risk. Example: rashes from
sulfa or ampicillin – usually do not represent
“true” allergies.
Immunizations
• Childhood immunizations: measles,
mumps, rubella, polio, diptheria, pertussis,
tetanus.
• Note last tetanus booster
• Last flu shot
• Pneumococcal vaccine, if indicated
• Hepatitis B
Screening Tests
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Last pap smear and result
Last mammogram, if indicated, and result
Lipid screen and result
Test of stool for occult blood and result
Sigmoidoscopy or colonoscopy if indicated
The most recent physical, dental, vision,
hearing, ECG, and chest x-ray.
Environmental Hazards
• Examples of employment hazards: inhalants, noise,
heavy lifting, psychological stress,machinery.
• Examples of hazards in the home: fire, stairs to climb,
inadequate heat, open gas heaters, inadequate toilet
facilities, concern about pest control, inadequate space.
• Examples of neighborhood hazards: noise, water and air
pollution, inadequate police protection, heavy traffic,
overcrowding, isolation from neighbors.
• Examples of community hazards: unavailability of stores,
market, laundry facilities, drug stores, no access to bus
line
NOTE
Women who work at home have been found
to have high levels of exposure to various
toxic cleaning agents….something to think
about!
ALSO – note if there are smokers in the
home, school or work environments
Use of Safety Measures
• Seat belts – actually it’s been found that
regular seat belt use is a predictor for
engaging in other valuable health
promotion activities!
• Car seats for children
• Shower handles for the disabled or the
elderly
Exercise and Leisure Activities
• Indicate what, if anything, the person is
doing for exercise…….whether formal or
informal. For example: in NYC, walking is
a necessity and also serves as a form of
exercise.
• Identifying both exercise and leisure
activities helps to highlight potential risks
for injury while also indicating attempts to
modify risks for cardiac and bone disease.
Sleep Patterns
• Identify how many hours per night the person
sleeps
• Indicate whether or not the person has difficulty
getting or staying asleep
• Indicate if there is difficulty breathing during
sleep or if there is noticeable snoring
• Indicate if the person is tired during the day in
spite of getting enough perceived sleep
Diet
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Attempt to get a 24 hour recall
Include beverages and snacks
Determine if this is a usual diet
Indicate whether there are food
“sensitivities”
• Note amount of caffeine intake per day
• Indicate changes in appetite
• Special diets
Current Medications
• Begin with the last 24 hours and include
prescription drugs, non prescription drugs,
vitamin and mineral supplements, home
remedies, homeopathic and herbal products.
• Ask about borrowed medicines
• Include names, dose, schedule, duration and
reason for use.
• Note: I often ask a person to bring everything
that they take when they come for their first visit
– amazing what you can find!
Tobacco, Alcohol and Illicit Drugs
• Include type, amount, duration and pattern of
use.
• Indicate if exposure to second hand smoke.
• There is a tendency to underestimate, especially
for alcohol use. Identify the type of alcohol
generally consumed first, then estimate the
amount taken.
• Indicate if alcohol is used to modify stress.
• Drinking companions or alone
Foreign Travel
• Especially important these days – as
noticed by the SARS outbreak.
• However, also important in terms of GI
complaints – many countries have
parasites in the drinking water that can
easily go undiagnosed for quite awhile,
once a person returns.
Sexual Activity
• Sexual orientation, level of activity, use of
contraceptives, problems
• Question regarding sexual violence.
• A comprehensive sexual history is
conducted only if there are indications of a
problem. (You will learn that in Advanced
Health Assessment)
FAMILY HISTORY
Common disorders
found in families:
• Hyperlipidemia
• Heart Disease
• Diabetes Mellitus
• Hypertension
• Myopia
• Kidney Disease
• Cancer (bowel,
ovarian and breast)
• Osteoporosis
• Mental Illness
• Alcoholism
• Arthritis
• Epilepsy
• Anemias
Focus
• Age and health OR age and cause of
death, of grandparents, parents, siblings
and children.
• NO need to get into aunts and uncles etc.
• Note if adopted or born via AI
• Can document using a Genogram
PSYCHOSOCIAL HISTORY
Components
1. Home situation
2. Significant others
3. Support Systems
4. History of Interpersonal Trauma
5. Daily life
6. Important experiences
7. Religious beliefs
8. Outlook on the present/future
Home Situation
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Urban, rural, suburban
Alone, with family members, with others
Number of rooms
Number and ages of other individuals in
home
• Feelings about home arrangements
Significant Others
• Informal support systems: family, friends,
neighbors.
• Most significant relationship in and out of
the home.
• Who does this person turn to when they
need help?
Support Systems
• Formal support systems: WIC, Medicare,
Medicaid, Meals on wheels, Food stamps,
SSI
• Semi formal support systems: School,
church, clubs
• Indicate satisfaction with social contacts
History of Interpersonal Trauma
• Inquire about rape, incest, abuse as a
child or spouse, other personal tragedies.
• Ease in discussion.
• Stage of resolution (denial, fear, anger,
adaptation).
• Resources.
• Always ask: Is anyone hurting you?
Daily Life
• General description of work, leisure and
rest
• Hobbies and/or methods of relaxation
• Community activities and involvement
Important Experiences
Ask this as an open ended sentence, you
will learn a great deal about a person!
Examples of some commonly shared
experiences that could have implications
for health include: school, military service,
work, marriage, childbearing, retirement.
Religious Beliefs
• Religious practices and rituals
• Spiritual advisors
• Association between religious beliefs and
state of health
• Relationship with an organized religious
group
Outlook on the Present/Future
• How does this person feel about her life
now?
• Where does she see herself in 1 year, 5
years?
• Is she optimistic?
• Is she pessimistic?
• Is she hopeful?
REVIEW OF SYSTEMS (ROS)
Of all the components in the health history,
this is the one that most nurses find
confusing……so take some time to
understand what this is about!
It’s best to begin the ROS with an
explanation – so the person has some
idea of why you are asking all these
questions when she came in with a CC of
say, fatigue .
What is the ROS?
• The ROS is a review of all current and pertinent
past symptoms, in order to be sure that no
pertinent clues have been missed by either the
provider or the care seeker.
• There is no practical limit or list of questions
which might be asked….it’s somewhat arbitrary,
based on the individual situation. For instance,
you would not ask a 65 year old woman, the
same questions you would ask a 22 year old
postpartum mom.
• The questioning proceeds in roughly anatomical
order so there is some sort of systematic
approach.
More ROS
• As much as possible, do not use medical jargon
because that would defeat the purpose!
• When you get a positive response, ask for
further information: “tell me more” or “tell me
about that”.
• Don’t be surprised if you uncover something
that belongs in the family history, or
hospitalization section….sometimes this line of
questioning jars the memory. If this occurs, do
not document this in the ROS but rather in the
appropriate section.
ROS Handout
Refer to the handout titled, Review of
Systems.
The questions on the left are phrased in lay
terminology, as much as possible,
according to system.
The right side is intended for you, the
practitioner, to be mindful of what you
might be looking for when asking these
questions.
Documenting the Health History
• First and foremost, this is NOT a short story
narrative!
• The history should be brief and to the point,
stating only and everything that is important.
• An organized systematic approach, using
specific headings, makes it easy for the reader
to extrapolate data without reading the entire
report. For instance, if I just want to check the
family history, I should be able to find it easily
and quickly.
Review – Major Components of a
Comprehensive Health History
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Identifying data
Chief complaint (CC)
History of Present Illness (HPI)
Past History
Current Health Status
Family History
Psychosocial history
Review of Systems
Helpful Study Hints
• Get some index cards
• Write the category of the health history on
one side (ex. Psychosocial hx)
• On the other side, write the components of
that category that should be addressed
• For the Review of Systems, you may need
more than one card!
More Study Hints
• Once you feel you know the components of the
history, find a volunteer who can spend about
one hour with you. Go through a mock history
with this person – without using any cards or
prompts!! Use the self assessment checklist to
see what you remembered and what you may
have forgotten.
• This is important, because it will tell you the
kinds of questions that you do not ask – and it is
a great way to learn . It also helps you to fine
tune your interview skills.
Sample History
• A sample history is included in this packet.
This will provide you with a framework to
document your findings.
Required Paper for this Program
• When you are ready, conduct and document a
comprehensive health history with someone who
has minimal health concerns and can spend at
least one hour with you.
• Before sending me this history, use the enclosed
self assessment sheet and correct what is
missing. Send a copy of the self assessment
sheet as well.
• NOTE: It’s best to complete this part of the
required material BEFORE proceeding to the
physical assessment section!