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
| Identifying and General Information | Client 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 Illness | Client 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?
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 Systems | Explanation (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 Referrals | Explanation (use complete sentences) |