Ch. The Health History Flashcards
What information does the health history contain
Biographical data Source of the history Reason for seeking care or chief complaint Current health or history of current illness Past health Family history Review of systems Functional assessment and ADLs
Ex of Biographical Data
Name Address and phone number Age and birth date Birthplace Gender Relationship status Preferred language Occupation (usual and present) – or daily activity pattern Source of information
Reason for Seeking Care
A brief statement in patient’s words, using quotation marks
Includes health maintenance, health promotion, or wellness needs
Ex. of Past Health
Childhood illnesses Accidents or injuries Serious or chronic illnesses Hospitalizations Operations Obstetrical history Immunizations Most recent examination date Allergies Current medications
Review of Systems
Only Subjective Data
Review past and current health state of each body system; double-check for omission of significant data; evaluate health promotion practices
Not objective or physical examination data
Evaluation of health promotion practice in relation to each body system
General overall health state – “How do you feel overall”
Skin, hair, and nails
Head – “protective gear?”
Eyes – “glasses – resent vision check?”
Ears – “hearing aides, wax cleaning – q tips”?
Functional Assessment,Including ADLs (activities of daily living)
Self-concept, self-esteem Activity and mobility Sleep and rest Nutrition and elimination Interpersonal relationships and resources Spiritual resources Coping and stress management Smoking history Alcohol Substance use Environmental hazards Intimate partner violence Occupational health
Developmental Considerations
Attention to ways ADLs are affected by normal aging process, chronic illness, or disability
Recognition of positive health measures
Focus may vary and additional questions may be needed related to age, pre-existing conditions, current medications, and functional assessment
