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 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?

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)