“Tan-tan-taaaan!!”: The Complete Health History

A complete health history report (min. 20 pages) on a living person was assigned of the first day of my Adult Health Assessment class. Dr. Maury insisted we begin writing the paper that same day. We (the class) replied with a bemused look on our faces. I could hear an orchestra of heart beats pounding a million miles a minute – a composition unlike anything John Williams put together. Gulping and nervously fiddling my Sharpie® pen between my fingers, I ask, “Will we receive a rubric or guideline?” He replies “…mmm…no?” I nodded consensually as if he reply didn’t murder me a little on the inside. Everyone else just replied with a loud and obnoxious “WHAAAAATT???”

Long story short, I’ve made it a point to research this stuff and create an outline of my own to go by and here I am here to share it with you.

I) Biographical Data

• Name
• Address
• Phone number
• Age
• Date of birth
• Birthplace
• Gender
• Marital status
• Race
• Ethnic origin
• Occupation

II) Source of History

• Who furnishes the information?
• Judge how well the informant seems and how willing he or she is to communicate?
• What is reliable? A reliable source often provides the same answer when a question is rephrased.
• Note any special circumstances in the interview such as an interpreter.

III) Reason for Seeking Care

• This is often a brief spontaneous statement made in the person’s own words that describes the reason for their visit.
• A symptom is a subjective sensation the patient feels from the disorder.
• A sign is an objective abnormality that you as the examiner may detect on physical examination or laboratory results.
• This statement made by the patient must be enclosed in quotation marks to indicate the person’s exact words.
• Always try to include a time frame. Sample statement: “I have had a sore throat for 3 days now and its just getting worse”

Note: Occasionally, a person may list many reasons for seeking care, however, the most important to the person may not be the one stated first. Focus on which is the most pressing concern and ask the patient which one prompted him or her to seek care now.                                                                                              

IV) Present Health or History of Present Illness

• For the well person, this is a short statement about the general state of health: “I feel healthy right now” or “I am healthy and active.”
• For the ill person, this section is   chronologic record of the reason for seeking care from the time the symptom first started until now.
• Isolate each reason for care identified by the person by saying “Please tell me about your headache from the time it started until the time    you came to the hospital.”

• Collect all data first. Although you might expect the person to respond in a narrative format without interruption from you, your final summary of any symptom the person may have should include eight critical characteristics:

1. 1.    Location – Ask the person to point to the location. If the problem is pain, note the precise site For example, “Head pain” is vague, whereas “pain behind eyes” or “jaw pain” are more specific. Note whether the pain is superficial or deep.
2. 2.    Character or Quality – This causes for specified terms such as burning, sharp, dull, aching, gnawing, throbbing, shooting, and viselike.
3. 3.   Quantity or Severity – Attempt to quantify the sign or symptom. Quantify the symptom of pain by asking: “On a 10-point scale, with 10 being the most pain you could possibly imagine and 1 being mild pain, tell me which you would rate your pain right now.”
4. 4.    Timing – This refers to the onset, duration, and frequency of the symptom. Record the specific date and time or state how long ago the symptom started PTA (prior to admission). Ask how long the symptom lasted? (duration), if it was steady (constant), or if it came and went during that time? (Intermittent), and if it resolved completely and reappear days or weeks later (cycle of remission or exacerbation)?
5. 5.   Setting – Where was the person or what was the person doing when the symptom began? What brings it on?
6. 6.   Aggravating or Relieving Factors – What makes the pain worse? Is it aggravated by weather, activity, food, medication, standing, bent over, fatigue, time of day, season, and so on? What relieves the symptom (ice pack, medication, rest)?
7. 7.    Associated Factors – This is the primary symptom associated with any others such as “urinary frequency and burning associated with fever and chills”. In this section, you will provide alcohol and tobacco use.
8. 8.    Patient’s Perception – Find out the meaning of the present symptom by asking them how it has affected them. “Is there anything you cannot do now that you could do before?” “What do you think it means?” This is crucial because it alerts you to potential anxiety if the person thinks the symptom may be ominous.

*My textbook also suggests a mnemonic device for these steps: “PQRSTU”

P: Provocative or palliative    R: Region or Radiation   T: Timing

Q: Quality or Quantity          S: Severity Scale           U: Understand Perception

Past Health

Childhood Illness: Measles, Mumps, Rubella, Chickenpox, Pertussis,  and Strep Throat

Accidents or Injuries:  Auto accidents, fractures, penetrating wounds, head injuries, and burns.

Serious or Chronic Illness: Asthma, depression, diabetes, hypertension, heart disease, HIV infection, hepatitis, sickle-cell-Anemia, cancer, and seizure disorder.

Hospitalizations:  Cause, name of hospital, how the condition was treated, how long the person was hospitalized, and name of physician.

Operations: Type of surgery, date, name of surgeon, name of hospital, and how well the person recovered.

Obstetric History: Number of pregnancies (Gravidity), number of deliveries in which the fetus reached full term (Term), number of preterm pregnancies (Preterm), number of incomplete pregnancies (Abortions), and number of children living (Living). For each complete pregnancy, note the course of pregnancy; labor and delivery; gender, weight, and condition of each infant; and post partum course. For any incomplete pregnancies, record the duration and whether the pregnancy resulted in spontaneous (S) or induced (I) abortion.

Immunizations: Measles-mumps-rubella, polio, diphtheria-pertussis-tetanus, varicella, hepatitis A and B, meningococcal disease, human papilloma virus, Haemophilus influenza type B, pneumococcal vaccine, influenza.

*Note the date of the last tetanus and tuberculosis skin test.

Last Examination Date: Physical, dental, vision, hearing, electrocardiogram, chest x-ray, mammogram, Pap test, stool occult blood, serum cholesterol.

Allergies: Note both the allergen (medication, food, or contact agent [fabric or environmental agent]) and the reaction (rash, itching, runny nose, watery eyes, difficulty breathing). If the allergen is a medication, be sure that the person does not identify the medication’s side effect as an allergy.

Current Medications:  Note all prescriptions and over-the-counter medications. Ask specifically about vitamins, birth control pills, aspirin, and antacids because many people do not consider these to be meds. For each medication, note the following: Name, dose, and schedule, and ask “How often do you take it each day?” “what is it for?” and “How long have you been taking it?

V) Family History

The best way to compile the patient’s family history is to have them complete a pedigree or genogram. A genogram is a graphic family tree that uses symbols to depict the gender, relationships, and age of immediate blood relatives in at least three generations (e.g. parents, grandparents, siblings).

Each relative’s medical condition should be recorded as well as other significant health data such as age and cause of death, tobacco, and alcohol use. Specify:

• Coronary heart disease
• Diabetes high blood pressure
• Stroke
• Obesity
• Blood disorders
• Breast/ ovarian cancer
• Colon cancer
• Sickle-cell anemia
• Arthritis
• Allergies
• Drug addiction
• Mental illness
• Suicide
• Seizure disorder
• Kidney disease
• Tuberculosis

Note: If the person is an immigrant, there are certain items you may want to consider in their health history.

Biographical Data

• When did the person enter the United States?
• What country did they come from?
• Under what conditions did they come to the US?
• Were they refugees?

Be sensitive in asking these questions as these questions may evoke painful memories in certain situations.

Spiritual Resources/Religion

• Assess certain procedures that may not be carried out. (i.e. administering blood to a Jehovah’s Witness, drawing large amounts of blood from a Chinese patient)

Past Health

• Take note of the possible immunizations given in their homeland. For example, was the person given Bacillus Calmette-Guerin (BCG)? This vaccine is not administered in the US however is used in many countries to prevent tuberculosis. Thusly, if a person was administered this vaccine, they will test positive in the tuberculin skin test and further diagnostic procedures must be done.

Nutritional

• What food and food combinations are taboos?
• What foods are associated with this person’s background and heritage?

VI) Review of Systems

The purpose of this section is to (1) evaluate the past and present health state of each body system, (2) to double-check in case any significant data were omitted in the Present Illness section, and (3) to evaluate health promotion practices.

Roughly, this evaluation is done from head to toe. If the Present Illness section covered one body system, you do not need to repeat all the data there.

When reviewing systems, avoid medical jargon when explaining findings to patient.

When recording findings, avoid writing “negative” after the system heading. You must record the presence and absence of all symptoms; otherwise the reader may not know what factors you asked about.

The evaluation should be carried out in the order as follows:

General Overall Health State

• Present weight (gain or loss, over what period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, seats 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 or lesion.

Hair

• Recent loss, change in texture. Nails: change in shape, color or brittleness.

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.

Ears

• Earaches, infections, discharge and its characteristics, tinnitus or vertigo,.

Nose and Sinuses

• Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstructions, 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.

Neck

• Pain limitation of motion, lumps and swelling, enlarged or tender nodes, goiter.

Breast

• Pain, lump, nipple discharge, rash, history of breast disease, any surgery on the breasts.

Axilla

• Tenderness, lump or swelling, rash.

Respiratory System

• History of lung diseases (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.

Cardiovascular

• Precordial or retrosternal pain, palpitation, cyanosis, dyspnea or exertion (specify amount of exertion [e.g. walking one flight of stairs, walking from chair to bath, or just talking]), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia.

Peripheral Vascular

• Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with poison, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis and ulcers.

Gastrointestinal

• 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 recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions (hemorrhoids, fistula)

Urinary System

• Frequency, urgency, nocturia, dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudiness or presence of hematuria), incontinence, history of urinary disease ( kidney disease, kidney stones, urinary tract infections, prostate), pain in flank, groin, suprapubic region, low back.

Male Genital System

• Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia.

Female Genital System

• Menstrual history, menarche, last menstrual period, cycle, duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and it’s characteristics, age at menopause, postmenopausal bleeding.

Sexual Health

• Explain to the client that you ask all other patients about their sexual health. Ask: Are they currently in a relationship involving intercourse? Are the aspects of sex satisfactory to the patient and partner? Are condoms used routinely? Is there is any dyspareunia (in females)? Changes in erection or ejaculation (in males)? Use of contraceptives? Aware of contact with partner who has had any STD infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, or syphilis)?

Musculoskeletal System

• History of arthritis or gout. In the joints: pains, stiffness, swelling (location, migratory nature),deformity, limitation of motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gat problems or problems with coordinated activities. In the back: any pain (locations and radiation to any extremities), stiffness, limitation of motion, or history of back pain or disk disease.

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 the 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 and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, and need for hormonal therapy.

VII) Functional Assessment (Including Activities of Daily Living)

The Functional Assessment measures a person’s self-care ability in the area of general physical health or absence of illness, ADLs, such as bathing, dressing, toileting, eating, walking, instrumental activities of daily living, or those needed for independent living, such as housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances; social relationships and resources; self-concept and coping; and home environment.

VIII) Self-Esteem/Self-Concept

• Education (last grade level completed, other significant training), financial status (income adequate for lifestyle and/or health concerns), value-belief system, (religious practices and perceptions of personal strengths).

IX) Activities/Exercise

• A daily profile reflecting usual daily activities should be recorded here. Ask if they need assistance doing any ADLs. Record leisure activities enjoyed and the exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring the body’s response to exercise).

X) Sleep and Rest

• Sleep patterns, daytime naps, any sleep aids used.

XI) Nutrition/Elimination

• Record diet by recall of food and beverages taken over the past 24 hours. Notice if the menu is typical of most days. Describe eating habits and current appetite. Ask who buys and/or prepares food. Record food allergies.
• Ask about usual pattern of bowel elimination and urinating including problems with mobility or transfer in toileting, continence, and use of laxatives.

XII) Interpersonal Relationships/Resources

• Ask client to describe role in the family. Ask about relationship with family, friends, and co-workers. Ask who they go to for support with a personal problem.

XIII) Spiritual Resources

• Many people believe in a relationship between spirituality and health, and they may wish to have spiritual matters addressed in the traditional health care setting. Use FICA questions to incorporate a person’s spiritual values into the health history.
• Faith: Does religious faith or spirituality play an important role in their life?
• Influence: How does their religious faith or spiritually affect the client’s thoughts?
• Community: Are they a part of any religious community or congregation? 
• Address: Ask if they would like you to address any religious or spiritual issues or concerns?

XIV) Coping and Stress Management

• Kinds of stresses in life, especially in the past year, any change in lifestyle or any current stress, and whether these have been helpful.

XV) Personal Habits

• Tobacco, alcohol or street drugs. Have they ever tried to quit?

XVI) Environmental Hazards

• Housing and neighborhood living, safety of area, adequate heat and utilities, access to transportation, and involvement in community services.

XVII) Intimate Partner Violence

• Begin with open-ended questions: “How are things at home?” and “ Do you feel safe?” Some may not realize they are in an abusive relationship and/or may be reluctant or unwilling to admit due to guilt, fear, shame, or denial.

XVIII) Occupational Health

• Has the client ever worked with any health hazards such as asbestos, inhalants, chemicals, or hard labor? Was protective equipment used? How much exposure? Were they aware of the health risks before beginning the job?

XIX) Perception of Health

Ask the person questions such as: “How do you define health?” “How do you view your situation now?” “What are your concerns?” What do you think will happen in the future?” “ What are your health goals?” “ What do you expect from us as nurses, physicians, (or other health care providers)?”

PHEW! Hope this helps!