Chapter 4: The Complete Health History

Question 1

Biographic Data

Answer 1

Name, age, gender, relationship status, birth date, birthplace, race and ethnic origin, address, phone, occupation, primary language, etc.

Question 2

Source of History

Answer 2

Record the person who furnishes the information (patient, parent, aid, etc.)

Judge their reliability and willingness to communicate

Question 3

Reason for Seeking Care

Answer 3

Brief statement in the person’s own words describing reason for visit:

“My surgical site looks red and is itchy”
“I’ve had chest pain for 2 hours”
“I’m here for my annual”

Question 4

Present Health or History of Present Illness (HPI)

Answer 4

Collect provided data and identify 8 critical characteristics

Ensure data is precise and accurate

Question 5

Eight Critical Characteristics:
PQRSTU

Answer 5

Provocative or palliative
Quality or quantity
Region or radiation
Severity scale: 1 to 10
Timing or onset
Understand patient’s perception of problem (effect on daily life)

Question 6

Past Medical History (PMI)

Answer 6

Childhood illness
Accidents, injuries
Chronic illness
Hospitalizations
Operations
Obstetrics hx
Immunizations
Last exam date
Allergies
Current meds

Question 7

Family History

Answer 7

Genogram

Question 8

Review of Systems (ROS)

Answer 8

Complete systems review
Head to toe
Avoid writing negative/none, etc.
Some systems have health promotions (Ex: wearing sunblock)

Question 9

Functional Assessment

Answer 9

ADLs

Question 10

Perception of Health

Answer 10

This is the patient’s understanding or view of their own health and how it affects their daily lives; also involves what their goals are and what they expect from their HCPs