EDGEWOOD COLLEGE

Department of Nursing

Nursing 211

HEALTH HISTORY GUIDE

 This form is to guide your health history interview and help organize and document your findings.

IDENTIFYING DATA

HEALTH STATUS

Reason for Seeking Health Care:  (Brief statement in client’s own words that describes reason for visit.)

Current Health Status:  (A chronological record of the reason for seeking care, from time of onset of symptoms until now.  Include P, Q, R, S, T, U.)

General State of Health:  (Client’s perception)

Medications/Drugs:  (Include home remedies, prescription and OTC)

Allergies: (Food, animals, medications, environmental - include reaction to allergen)

Past Health Status:

            Childhood Illnesses/Injuries:

            Immunizations:  (Give dates of most recent)

            Adult Illnesses/Injuries:

            Hospitalizations/Surgeries: (Give year & type of surgery.)

            Past & Present Exposure to Environmental Hazards:  (work, home)

Family Health:  (Age & health or age & cause of death of blood relatives, parents, gr. parents & siblings; also spouse & children if appropriate.  Diseases such as heart disease, hypertension, stroke, diabetes, blood disorders, cancer, sickle cell anemia, arthritis, obesity, alcoholism, mental illness, seizure disorder, kidney disease, or TB).

Home Environment:

            Physical Environment:  (including but not limited to  emergency evacuation plan, fire extinguisher,seat belts,      helmets, electricity, water (city or well) (check nutrients bacteria, flouride), water temperature, telephone, steps,                 storage of chemicals/medications, smoke/CO detectors, Do you check your detector routinely?)

                Psychosocial Environment:  (including but not limited to safety in the neighborhood & safe at home, crime      watch preventions program)

PHYSIOLOGIC MODE:

1.  Activity and Rest: (Any Areas of Concern: Activity, Joint pain or stiffness, Back pain, limited ROM, weakness, Rest - insomnia,

       excessive sleeping; Helpful to have client describe a typical day).

            Ability to perform ADL’s:

            Use of prosthesis or mobility aids:

            Sleep patterns - use of sleeping aids; daytime naps:

Health Promotion Practices:

            Exercise:  (type, frequency, times per week)

            Leisure activities enjoyed:

2.  Oxygenation:  (Any areas of concern:  breathing problems, chest discomfort, edema, discoloration, tingling or numbness of extremities; high BP)

            Activity tolerance:  (any shortness of breath, chest discomfort,  If so, how much activity produces symptoms?;.)

            Smoking habits:  (Has client ever smoked; Use of tobacco products; Attempts to quite?; Used any aids?; exposure to second hand                 smoke).

            Health Promotion Practices:  (Amount of long-term standing/sitting; habit of crossing legs at knees; use of support                 hose).

3.  Nutrition:  (Any areas of concern:  problems with mouth/teeth/swallowing; problems with stomach, colon such as heartburn, indigestion, 

       excess gas; changes in diet, weight, appetite; any restrictions)  Ideal weight for you?  Satisfied with your weight?  What   

       would you consider your ideal weight & how far are you from that?  When was the last time you were at your ideal weight?)

            Typical 24 hour Diet:

            Eating Patterns:  (How often, with whom, frequency of eating out).

            Food likes/dislikes:

            Health Promotion Practices:  (use of supplements; daily intake of caffeine and alcohol; finances & transportation availability                 for shopping).

4.  Fluid and Electrolytes:  (Any concerns with: edema of hands/feet)

            Fluid Intake:  (Include typical 24 hour intake).

            Sodium:  (Is salt added to foods; use of processed foods).

5.  Elimination:  (Any concerns with:  incontinence, diarrhea, discomfort, unusual frequency)

            Urinary Frequency, Appearance:

            Bowel Movement Frequency, Appearance:  (use of laxatives, stool softeners).

            Health Promotion Practices: 

                        Fiber in diet, exercise, fluid intake, routine elimination practices:

6.  Protection:  (Any concerns with: skin, hair, or nails, such as rash, bruises, itching; changes in moles/pigmentation.  (A, B, C, D)

            Health Promotion Practices:  (Amount of exposure to sun and/or tanning beds; use of sunscreen.  Care of skin, hair, nails; self          skin examination)

7.  Senses:  (Any concerns with:  senses of touch, taste, smell , sight, hearing and/or pain).

            Vision, Glasses, Contacts:

            Health Promotion Practices:  (last eye exam, glaucoma exam; use of sunglasses).

            Hearing, Hearing Aids: 

                        If hearing loss, how does it affect daily life.

            Health Promotion Practices:  (method of cleaning ears, exposure to environmental noise or                                                                             loud music).

            Dental Care:  (dentures, bridges, problem with teeth, etc.)

            Health Promotion Practices:  (last dental exam, method & frequency of cleaning teeth)

8.  Endocrine Function:  (Any Concerns With: excessive thirst, sweating; intolerance to cold or heat, history of diabetes, thyroid          problems)

9.  Sexuality/Reproduction:

            Males:  (Any Concerns With: Penile or testicular pain, discharge, lumps.  Satisfaction with sexual function.)

            Health Promotion:  (practices testicular self-exam, frequency.  Use of contraceptive & STD prevention; Prostate check                        over age 40.)

            Females: (Any Concerns With:  vaginal itching, discharge, abnormal mentrual bleeding, PMS.  Last menstrual period, cycle, duration, dysmenorrhea; age at menopause; & at menarche, menopausal signs/symptoms; satisfaction with sexual function; anticipating becoming pregnant in the near future.)

            Health Promotion:  (BSE frequency; Last PAP and gyn check-up; hormonal replacement therapy; mammograms;                                         use of contraceptives & STD protection.)

10.  Neurologic:  (Any Concerns With: changes in gait, coordination, attention span, alertness, memory.  Dizziness, numbness, tingling,
 weakness).

SELF-CONCEPT MODE:

Physical Self:  feelings about appearance/body

Personal Self:  description of self as person; perception of personal strengths  How do others describe you?

Values and Beliefs:  (religious practices)

How do you express feelings:  (affection, caring, upset)

Aspirations: (able to attain goals -5/20 yr.)

Health Promotion Practices:  What things do you do to make yourself feel good about yourself?  Emotional, physical behaviors to sustain health?  Have you been able to do it - if not, why not?

ROLE FUNCTION MODE

            Family Structure:

            Living Situation:

            Family Role/Responsibilities:  (What is your role in the family?  What does family expect of you?  Are you able to meet                 expectiations?)

            Work Role/Responsiblities:  (What is your role at work?  Are you able to meet expectations?)

                Other Roles/Responsibilities & Achievement of Them:

            Health Promotion:  (What do you do to better prepare yourself for your roles in life?  How do you balance the various expectations for your time & energy?)

INTERDEPENDENCE MODE

            People Close To:

            To whom could you go for support:  (family, social)

            Amount of time spent alone: (Is it pleasurable or isolating?  Satisfied with amount of time alone?)

            Time spent with others:  (obligation or desire, satisfied with amount of time with others?)

            Pets:

            Health Promotion:  (What do you do to develop, maintain or improve relationships with others?)

ADDITIONAL DATA

SUMMARY OF HEALTH HISTORY

Return to Weekly Schedule/Assignments.