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Health History

Health History

Health History. The health history must be on an adult client (18-64 years of age) OR a geriatric client (age 65 and older). For an adult client, use the Adult Health History form. For a geriatric client, use the Geriatric Health History form.
Students will receive a zero if the history is not done on a client within the given age criteria. Use the form provided for each history in the course. A sample adult history is available in the course.
All data is subjective and comes from interviewing the client. DO NOT include physical exam (objective data) findings.
Details in each section and system must be addressed individually using concise and complete sentences. Uninformative answers such as “within normal limits” or “denies all problems” are NOT acceptable and will earn zero points.
In the Priority System and Health Promotion Recommendations sections, use the data from the health history to determine three health promotion recommendations and the rationale for each one. Include the relevant data in the health history in the rationale.
Guidelines Points Possible
The first history is completed on an adult client (18-64 years) OR a geriatric client (age 65 and older). Used the appropriate form. P/F
Interview date, initials, age, identifying and general information, source and reliability of information 5
Chief concern and history of present illness
5
Past medical history; geriatric history includes functional assessment 20
Personal & social history 20
Review of systems 20
Priority systems 10
Health promotion recommendations/referrals 10
Scholarly writing: To include, but not limited to clarity, grammar, concise and complete sentences, appropriate terms, etc. 10
Total 100
Due Date
Feb 27, 2022 11:59 PM
Attachments
Adult History Form v6.docx (33.16 KB)
Geriatric History Form v6.docx (33.15 KB)
https://spcollege.ensemblevideo.com/hapi/v1/contents/permalinks/j6LQn9o4/view Link to more information.

 

Health History: Why is it important to know my family health history?

Health History

Health History

 

Identifying and General InformationClient Information (use complete sentences)
Gender 
Race and ethnicity 
Birth date 
Birthplace 
Languages (fluent) 
Religious affiliation 
Education (highest level) 
Advanced directives: Living will, healthcare surrogate, durable power of attorney, organ donation 
Source and reliability of information: Identify if client or another person is providing information. If someone other than client is providing information, state relationship to client 

 

 

Chief Concern and History of Present IllnessClient Information (use complete sentences)
Chief concern: State reason client is seeking care in the “client’s own words” and explore history of present illness by completing OLDCARTS below.

If no chief concern, state annual exam and leave OLDCARTS blank below.

 
Onset 
Location 
Duration 
Character/quality 
Aggravating/associated factors 
Relieving factors 
Temporal factors 
Severity 

 

 

 

 

Past Medical History Client Information

(Explore positive findings, list specific denials, and use complete sentences)

General health: Usual health status (excellent, good, fair, poor); recent change 
Childhood infections: Chicken pox, measles, mumps, rubella, whooping cough, scarlet fever, rheumatic fever, diphtheria, polio 
Diagnosed health problems and treatment: List all congenital and acquired disorders, diseases, infections, and injuries; year of diagnosis; treatment details; significant diagnostic/laboratory results; inpatient/length of stay or outpatient; complications; ongoing problems 
Current medications: Current prescription and over-the-counter medications, supplements; year started, name, route, dose, frequency, taken as prescribed (if not, explain). 
Immunizations: Seasonal influenza, polio, diphtheria, pertussis, tetanus toxoid, hepatitis B, measles, mumps, rubella, Haemophilus influenza, varicella, meningococcal, pneumococcal, human papillomavirus, shingles; COVID-19; unusual reaction. 
Allergies: Drugs, food, other agents; reaction 
Transfusions: Reason, date, number of units; reaction 
Obstetric history (females): Menses or menopause, no. of pregnancies, live fetuses (full-, pre-term), type of delivery, number of terminations (spontaneous, intentional) 

 

Personal and Social History

Client Information

(Explore positive findings, list specific denials, and use complete sentences)

Cultural, religious beliefs: Language, health beliefs and practices, family relationships 
Living conditions: Type of residence, members in household, animals, amenities (water, electricity, etc.), smoke alarms 
Occupation: Current and prior work, duration of each, hours per day, shift, physical/mental strain; temperature, toxins (chemicals, radiation, asbestos); protective devices required/used, military service 
Alcohol: Type, amount, frequency, duration, cessation, signs of withdrawal, support group 
Tobacco, e-cigarette, vaping: Type, amount, frequency, duration, packs per day, cessation, secondhand smoke 
Drug use and/or abuse: Opioid, marijuana, illegal drugs, and/or addictive prescription drugs; Type, amount, frequency, duration, cessation methods, support group 
Diet: Cultural or religious foods/practices; eating pattern, typical meals/foods, meal supplements 
Sexual activity: Sexually transmitted infection/protection, pregnancy protection 
Sleep: Amount, quality 
Exercise: Frequency, type, duration, safety devices 
Driving safety: Seatbelt, phone/device use while driving 
Stress: Sources, degree 

 

Review of Systems

Client Information

(Explore positive findings, list specific denials, and use complete sentences)

General constitutional symptoms: Fever, chills, fatigue, night sweats, unintentional weight change 
Skin: Lesions, dryness, pallor, color change, moles/changes, easy bruising, unusual odor, sun exposure, sun protection 
Hair: Loss, change in texture, itching, hair dye 
Nails: Natural or acrylic nails, change in nails, brittleness, fungal infection 
Head and neck: Headaches, injury, dizziness, loss of consciousness, swelling, lumps, pain 
Eyes: Visual acuity, color blindness, glasses/contacts, blurring, double vision, light sensitivity, pain, dryness, redness, swelling, trauma, eye drops, sun glasses, last eye exam and results 
Ears: Earaches, infections, discharge, vertigo, tinnitus, hearing loss/aid 
Nose and sinuses: Sense of smell, obstruction, bleeding, postnasal discharge, sinus pressure/pain 
Mouth and throat: Sense of taste, voice change, tongue change, difficulty swallowing, tonsils, soreness/pain, abscess, ulcer, mass, gum bleeding or swelling, natural teeth/dentures, toothaches, caries/fillings; brushing, flossing, mouthwash; last dental exam and results 
Respiratory: Snoring, dyspnea, shortness of breath wheezing, cough, hemoptysis, sputum, infections, exposure to tuberculosis, last chest x-ray and results 
Cardiovascular: Chest pain, palpitations, cyanosis, murmur, orthopnea, paroxysmal nocturnal dyspnea, last electrocardiogram (ECG) and results 
Peripheral vascular: Coldness, numbness, tingling, edema, discoloration, claudication, thrombosis 
Gastrointestinal: Appetite, intolerance to any food, pain, heartburn, nausea, vomiting, constipation, diarrhea, change in stool, incontinence, bleeding, hemorrhoids, laxatives, endoscopic tests and results 
Genitourinary: Dysuria, flank or suprapubic pain, frequency, urgency, nocturia, hematuria, hesitance, incontinence,  infection 
Musculoskeletal: Pain, stiffness, swelling of joints, limited movement, cramps, weakness, problem with gait, deformities, assistive devices 
Neurologic: Syncope, tics, tremors, paralysis, aphasia, problems with sensation or coordination 
Mental status: Emotional state, social interaction, mood changes, depression, anxiety, suicidal thoughts, memory loss, confusion 

 

What are the 4 components of the health history?

Health History

Identify 2 systems that require thorough investigation during the physical exam; and provide your explanation (based on the patient information) to support the choices.

Priority SystemsExplanation (use complete sentences)
  
  


Identify 2 priority health promotion activities to recommend for the client; provide your explanation (based on the patient information) to support recommendations.

Health Promotion Recommendations and/or ReferralsExplanation (use complete sentences)
  
  

 

Calculate the Price

Approximately 250 words

Total price (USD) $: 10.99