Health History Guide
Name
College

Health history

Identifying   data
Date of history                                          
Examiner
Name                                                                       
Address

Phone number
Age
Sex
Race
Place of Birth
Marital Status
Significant Other
Employer
Occupation
Religion
Primary Language
Secondary Language
Source of referral
Source of history

Reliability

Chief complaints/reason  for  visit

Present illness:
Time of onset
Type of onset
Original Source
Severity
Radiation
Time relationship
Duration
Course
Association
Source of relief
Source of aggravation

Date, time...?
How:  Sudden? Gradual?
Triggers, what were you doing?
Interfere with ADL's?
Pain, direction it travels?
How often, when?
How long an episode?
Getting better, worse?
Lead to others?
Changes in medications, diet?
What makes it worse?

Past history
General State of Health:
Childhood Illnesses: (measles, mumps, rubella, whooping cough, chicken pox, scarlet fever, rheumatic fever, polio)
Adult Illnesses: (HTN, CAD, DM, Lung...) 
Psychiatric Illnesses 
Accidents and Injuries 
Operations 
Hospitalizations 
Obstetric 
Current health status

Current Medications (prescription or OTC)

Allergies (food/medications)  
 
Screening Tests (PPD, Pap, Mammograms, stools...)

Immunizations (tetanus, pertussis, diphtheria, polio, mumps, measles, rubella, influenza, Hepatitis B, Flu, Pneumococcal)
Obstetric 

Family history: (Age and health or age and cause of death)
Maternal/Paternal Grandparents
Parents
Aunts/Uncles
Siblings
Spouse
Children

Genogram

Review of systems
General: Overall state of health, changes in ADL's, weight, fatigue, fever, increased infections.
Skin: Rashes, lumps, sores, itching, dryness, color change changes in hair or nails.
NEUROLOGIC: Seizures, headaches, paralysis. Numbness, weakness, syncope, restless, tremors, blackouts.
Eyes: Vision, glasses, contacts, ? Last eye exam, pain, redness, excessive tearing, double vision, blurred vision, glaucoma, cataracts.
Ears: Hearing, tinnitus, vertigo, earaches, infections, discharge ? Hearing aids.
Nose and Sinuses: Frequent colds, nasal stuffing, discharge, hay fever.
Mouth and throat: Condition of gums and teeth, dentures, last exam, dry mouth, frequent sore throats hoarseness.
Neck: Lumps, "swollen glands", goiter, pain, stiffness.
Breast: Lumps, pain, nipple discharge? Self-exam.
Respiratory: Dyspnea, SOB, pain, wheezing, crackles, orthopnea, (?) Pillows, cough, sputum (color, quantity), emphysema, bronchitis, asthma, URI, chest x-ray.

Cardiac: Heart trouble, high blood pressure, rheumatic heart fever, murmurs, palpitations, chest pain, dyspnea. paroxysmal nocturnal dyspnea, edema, EKG, other heart test results.
Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea, vomiting. Frequency of bowel movements, change in pattern, rectal bleeding or black tarry stools, hemorrhoids, constipation. diarrhea. Abdominal pain, food intolerance, excessive belching or passing gas. Jaundice, liver or gallbladder trouble, hepatitis.
Urinary: Frequency, polyuria, nocturia, burning or pain on urination, hematuria, urgency, hesitancy, dribbling, UTI's, stones.
Genital:
Male: Hernia, discharge, testicular pain or masses, history of STD's and treatments, Sexual preference, interest, satisfaction, and problems.
Female: Age of menarche; regularity, frequency, and duration, amount of bleeding.bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension, age of menopause, menopausal symptoms, post-menopausal bleeding. If born before 1971, exposed to DES from maternal use. Discharge, itching, sores, lumps, STD's and treatment. Number of pregnancies, deliveries, abortions, complications of pregnancy, birth control methods. Sexual preference, interest, function, satisfaction.
Peripheral vascular: Intermittent claudication, leg cramps, varicose veins, past clots.
Musculoskeletal: Muscle or joint pains, stiffness, arthritis, gout, backache.
Hematologic: Anemia, easy bruising or bleeding, past transfusions and any reaction.
Endocrine: Thyroid trouble, heat or cold intolerance, excessive sweating, diabetes, excessive thirst or hunger, polyuria.
Psychiatric: Nervousness, tension, moods, depression, memory

Functional Assessment  (Including Activities of Daily Living)
Self-Esteem, Self-Concept
Financial Status 
Value-belief system 
Self-care behaviors 
Activity/Exercise 
ADL’s
Leisure activities 
Exercise pattern 
Other self-care behaviors 
Sleep/Rest 
Nutrition/Elimination 
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 getting along with family, friend, coworkers, classmates 
Get support with a problem from 
How much daily time spent alone? 
Is it pleasurable or isolating? 
Other self-care behaviors 
Coping and Stress Management
Describe stress in life now 
Change in past year 
Methods used to relieve stress 
Are these methods useful?
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 No
Date last alcohol use 
Amount of alcohol that episode 
Out of last 30 days, on how many days had alcohol? 
Ever had a drinking problem? 
Any use of street drugs? Specifically
Marijuana                           Amphetamines                     Heroin 
Cocaine                               Barbiturates                         Other 
Crack Cocaine                    LSD
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? 
Involvement in community services 
Hazards at workplace or home 
Use of seatbelts 
Travel or residence in other countries 
Military service in other countries 
Self-care behaviors 
Occupational Health
Jobs held
 Satisfaction with present and past employment
 Current place of employment
Please describe your job 
Work with any health hazards? 
Any equipment at work designed to reduce your exposure? 
Any 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 
Reaction to illness
 Coping patterns/mechanisms
 Value of health
What are your concerns 
What do you expect will happen to your health in future? 
Your health goals 
Your expectations of nurses and physicians 
 Educational level
 Highest degree or grade level attained
Judgment of intellect relative to age
Patterns of health care
Dental care
Preventive care
Emergency care
Developmental data:
Summary of developmental data and current functioning.
Use Erikson’s stages of development.

Nutritional data: ( see attached)
Identified risk  factors:
Health promotion activities:

NUTRITIONAL ASSESSMENT

Client's Height _______________
Weight ______________________

Projected Calories _____________   -------
Recommended weight

24-Hour Diet Recall;
TIME	FOOD EATEN	CALORIE AMOUNT	
BREAKFAST			
LUNCH			
DINNER			
SNACK			

FOOD CATEGORIES
	SERVINGS NEEDED
	SERVINGS EATEN
	DIFFERENCE
	
Animal Protein
	2

	
Vegetable Protein
	2

	
Dairy products calcium rich
	4

	
Whole grains, breads and cereals
	4

	
Vitamin c-rich foods
	1-2

	
Green.leafy vegetables
	1-2

	
Other fruits and vegetables
	2

	
Fats and oils

	
	
Other foods

	

Comments:

Suggestions Made: 
Increased calories 	     	___________	        Decrease fat		______________
Decrease sugar   	   	____________	        Increase fiber		______________
Increase number of meals 	__________	        Other			______________
Referred to food programs

Client's evaluation of own diet (circle one):
Excellent	Good 			Fair			Poor

References