Health History Flashcards
What is included in the biographical data section of health history?
- name, address, phone #
- dob
- birthplace, gender, marital status, sex assigned at birth
- ethnicity
- occupation
- religion
- primary language
- communication needs
Reason for seeking care
- illness
- symptom
- chief complaint/presenting problem
Perception of Health
- definition of health
- expectation
- hopes/plans for health
OLD CARTS used for history of present illness
onset location duration characteristics aggravating or alleviating factors related symptoms treatment severity
Symptoms vs signs
SYMPTOMS= patient's self report, can be described only by person affected SIGNS= detectable by observer , measured or tested against a standard
Past Health includes…
- childhood illness
- accidents/injuries
- illnesses
- hospitalizations
- surgeries
- obstetric history
- immunizations
- last exam date
- allergies
- current meds
Subjective head to toes evaluation of past and present state of each body system
Review of Systems
Overall health state section of ROS
- recent weight changes
- nutrition concerns (obesity, weight loss)
- fatigue
- fever
- night swears
- chills
- energy level/ activity
What is intermittent claudication?
Pain on use
-discuss in peripheral vascularWith urinary
what do you ask about for kids?
bedwetting and toilet training
What section does jaundice go in?
GI
What section does history of falls go in?
Musculoskeletal
What does in hematological?
- bleeding tendency of skin/mucous membrane
- bruising ease
- blood transfusion hxs
Where does diabetes go?
Endocrine sxs
Psychosocial
-finances
-military benefits
-exercise
-sleep
-safety
-tobacco use
-support sxs
-stress
behavior/enviro/social/financial/edu/occupation/housin
