Health History

General

Family

Teach/Learn

Current Health History of present illness, knowledge of problem, perception of health and quality of life, limitations, management of limitations, health/life goals

Socialization

Pysch. Profile Self concept, current stress levels, coping mechanisms, emotional status, mood, appearance, affect

Race, language, religion, marital status, insurance, contact person, relationships, advance directives, reason for admission, date of admission, last hospitalization, occupation, past hospitalizations & surgeries, medical history, past injuries, allergies, geographic exposure

Medication history, quality of relationships, support systems, birth order

Family history of: MI, COPD, HTN, DM, TB, CA, arthritis, ETOH, Alzheimer's, hyperlidemia, obesity Self-Care Eating, hygiene, dressing, continence, toileting, mobility

Education level, developmental status, desire to learn, knowledge of condition, information you taught, barriers to learning, compensation for barriers, questions asked

Hobbies, social patterns, formal activities, actives/exercise, typical day

Spiritual Beliefs/practices, how do they get through the difficult times, source of strength/hope, meaning and purpose of life

Rest/Sleep Usual pattern, interference's?, sleeping inducing agents?

Sexuality How are touch needs met?, concerns, health related info (pap smear,

Mental/Cognitive LOC, orientation, retention/recall, judgement, three stage command, language, calculation, mental health,

Medications Rx, OTC, vitamins, minerals, herbs

pain, kids, menopause, age of meses, discharge, impotence)

appropriate behavior, facial expressions, attention span, memory, eye contract, posture, environment (home, work, interview)

Physical Exam

Head Injuries, concussions, headaches, fainting

Integument Rashes, allergies, sores, jaundice, hair loss, nails, texture, birthmarks, moles, infections

Eyes Last exam, corrective lenses?,, itching, burning, tearing, blurring, spots, glaucoma, cataracts

Ears Pain, changes, infections, discharge, hearing aids, dizziness, tinnitus, how do they clean them, hearing test

Nose/Sinus Colds, allergies, epistaxis, drip, stuffy, changes, pain, sensitivity

Oral/Throat Teeth/gums, sore, bleeding, lumps, spots, toothaches, cavities, swallow, chew, dental wear, taste, cold sores, exam

Neck ROM, goiter, lumps, pain,

Neuro Fainting,

Psychiatric Nervous,

Breasts/GYN Lumps,

Cardiovascular Chest pain,

Respiratory Dyspnea, cough,

stiffness, lymphadenopathy

dizziness, seizures, numbness, blackouts, tremors, paralysis, disorientation

mood changes, psych Rx, memory changes

discharge, pain, swelling, BSE, dimpling, changes, mammogram, STD, # of pregnancies, abortions, miscarriages, yeast infections, PMS, itching Hematological Anemia, bleeding, bruising, blood type, transfusions,

palpitations, HTN, murmurs, varicosities, fatigue, edema, pain, cramps, EKG, orthopenea

wheeze, sputum, pain, fatigue, CXR, asthma, bronchitis, pneumonia, TB, SOB

Nutritional 24 hr diet recall, intake, frequency, # of meals/day, quantity, weight patterns

Gastrointestinal Appetite, weight loss/gain, nausea, vomiting, gas pain, stools, BM, ostomy, heartburn, enemas, diarrhea constipation, gall bladder

Urinary Frequency, pain, blood, usual pattern, hernia, discharge, STE (lumps, masses), STD

Endocrine polydipsia, polyuria, diaphoresis, temperature sensitivity, change in activity, heat/cold intolerance

Musculoskeletal Pain, stiffness, aids, difficulty, ROM, amputation, crepitus