Health History

Question 1

Begining of health assesment

Answer 1

Introduce self

Question 2

2. a brief statement of pts reason for coming to us in their own words

Answer 2

reason for seeking care/ chief concern

Question 3

3. trying to get a full understanding of pts problem they came in for using OLD CARTS

Answer 3

history of presenting illness

Question 4

4. The pts current conditions they have
   what medication they are taking, OTC, supplements, or herbal meds
   what allergies they have: food, meds, seasonal, or environmental. what reactions they have and what meds they take to prevent allergies

Answer 4

present health history

Question 5

4. The pts current condition they have
   what medication they are taking, OTC, supplements, or herbal meds
   what allergies they have: food, meds, seasonal, or environmental. what reactions they have and what meds they take to prevent allergies

Answer 5

present health history

Question 6

5. childhood illness: ask all illness
surgeries
hospitalizations
accidents or injuries
immunizations
last exam
OB history:

Answer 6

past health history

Question 7

ask up to 3 gen
Mother, father, paternal grandparents, and maternal grandparents
ask for common diseases: cancer, diabetes, substance abuse stroke etc

Answer 7

family history

Question 8

Ask personal status
family and social relationships
diet
functional ability
mental health
Drugs, alcohol, substance abuse
health promo activities 
environment

Answer 8

personal and psychosocial history

Question 9

Ask questions of each body systems and ask in details

Answer 9

review of systems