Health History

Health History Biographical Data (name, address and phone number; age and birthday; birthplace; gender; marital status; race; ethnic origin, occupation – both usual and present) Source of History (WHO: patient, parent, spouse, partner; RELIABILITY) Reason for Seeking Care (patient’s own words, in quotes) Present Health or History of Present Illness (OLDCARTS) O: Onset: When did the problem first start? Setting and circumstances - chronologic sequence of events. Manner of onset (Sudden vrs. Gradual) What was the person doing? What seems to bring on the symptoms?) L: Location: Where is it? Exact location, localized or general, radiation patterns. D: Duration: How long does the problem last? Is it intermittent? Is it constant? What is the duration of each episode? C: Character: nature of symptom. Describe the sign or symptom. How does it feel (sharp, dull, aching, throbbing), how does it look (shiny, bumpy, red, swollen, bruised), how does it sound (loud, soft, rasping), how does it smell (foul, sweet, pungent ), how intense or severe is it, how much ? A: Aggravating Factors: Food, activity, rest, certain movements, nausea, vomiting, diarrhea, chills, etc R: Relieving factors: Prescribed or self medicating therapies; Alternative or complimentary therapies; their effect on the problem T: Temporal factors: Frequency; relation to other symptoms, problems, functions, symptom improving or worsening over time S: Severity: How bad is it? (on a scale of 1 – 10) Is it getting better, worse, staying the same? effects on ADL’s and patient’s lifestyle– cannot go to work);

Past Health History (childhood illness, accidents/injuries/disabilities, serious/chronic illness, hospitalizations, surgeries, obstetric history, immunizations, transfusions, last examination (date, what for), allergies (include drugs as well as environmental) and type of reaction, current medications with dose and frequency – both prescribed and OTC)

Family Health History Age and health of blood relatives (parents, grandparents, siblings), or age and cause of death of blood relatives (parents, grandparents, siblings). Age and health of spouse and children. Family history of heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, tuberculosis. Construct a genogram or family tree to show the information gathered.)

Cross Cultural Care

When person entered country, circumstances in previous country(refugee, torture issues); identify any particular spiritual resources or religious practices that would have an impact on health or health practice(administration of blood etc.); past health r/t immunizations; health perception – individuals description of health and illness and current problem; nutritional considerations that might be taboo

Health History continued Review of Systems Overall Health State: Describe any recent weight changes such as gain or loss(time frame and manner) , any fatigue, weakness or malaise; any fever or chills, any sweats or night sweats)

Skin, Hair, Nails: Skin: History of skin disease (eczema, psoriasis, hives) Pigment or colour change Change in Mole Excessive dryness Excessive moisture Pruritis Excessive Bruising Rash Lesion Health Promotion: (sun exposure, self care for skin)

Yes

No

____

____

____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____

Hair: Recent loss Change in texture Health Promotion: (self care for hair)

Nails: Change in shape, colour or brittleness

Yes ____ ____

No ____ ____

____

____

Health Promotion: (self care for nails)

Head and Neck:

Yes

No

Head: Unusually frequent or severe headache Any head injury Any dizziness(syncope) Any vertigo

____ ____ ____ ____

____ ____ ____ ____

Neck: Any Pain Any limitation of motion Any lumps or swelling Any enlarged or tender nodes Any goiter

____ ____ ____ ____ ____

____ ____ ____ ____ ____

Eyes and Ears: Eyes: Difficulty with vision ____ ____ (decreased acuity, blurring, blind spots) Any eye pain ____ ____ Diplopia or double vision ____ ____ Any redness or swelling ____ ____ Any watering or discharge ____ ____ Glaucoma ____ ____ Cataracts ____ ____ Health promotion: Wearing of glasses or contacts; last vision check or glaucoma check, how is individual coping with any vision loss?

Ears: Earaches Infections Discharge Tinnitus Vertigo

Yes ____ ____ ____ ____ ____

No ____ ____ ____ ____ ____

Health promotion: Hearing loss(how loss affects daily life, hearing aid use), exposure to environmental noise, method of cleaning ears)

Nose, Sinuses, Mouth and Throat: Nose and Sinuses: Discharge and characteristics Frequent or severe colds Sinus Pain Nasal Obstruction Nosebleeds Allergies or Hay Fever Change in Sense of Smell

Yes _____ _____ _____ _____ _____ _____ _____

No ____ _____ _____ _____ _____ _____ _____

Mouth and Throat: Mouth Pain Frequent sore throat Bleeding Gums Toothache Lesion in mouth or tongue Dysphagia Hoarseness Voice Change Altered taste History of tonsillectomy

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____

Health Promotion: pattern of daily dental care; use of prostheses (dentures, bridge), and last dental checkup. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ___________________________________________________

Respiratory System: History of:

Yes

No

Asthma _____ _____ Emphysema _____ _____ Bronchitis _____ _____ Pneumonia _____ _____ Tuberculosis _____ _____ Any chest pain with breathing _____ _____ Wheezing or noisy breathing _____ _____ Shortness of breath _____ _____ How much activity produces shortness of breath? ____________________________________________________________________________________ _____________________________________________________________________________________ Cough _____ _____ Sputum (Colour, Amount) ______________________________________________________________________________________ ______________________________________________________________________________________ Hemoptysis _____ _____ Toxin or Pollution Exposure _____ _____ Health Promotion: Last chest x-ray study? Smoking history? ______________________________________________________________________________________ Cardiovascular System: Precordial or retrosternal pain Palpitation Cyanosis Dyspnea on exertion If yes, specify amount of exertion _______________________________

_____ _____ _____ _____

_____ _____ _____ _____

Orthopnea _____ _____ Paroxysmal nocturnal dyspnea _____ _____ Nocturia _____ _____ Edema _____ _____ History of heart murmer _____ _____ Hypertension _____ _____ Coronary Heart Disease _____ _____ Anemia _____ _____ Health Promotion: date of last ECG or other heart tests ______________________________________________________________________________________ Peripheral Vascular: Any coldness, numbness or tingling _____ _____ Any swelling of legs; (Time of day, activity) _____ _____ ______________________________________________________________________________________ Discolouration in hands or feet (bluish red, mottling) _____ _____ Varicose veins _____ _____ Thrombophlebitis _____ _____ Ulcers _____ _____ Intermittant claudication _____ ____ Health Promotion:

Does work involve long term sitting, standing? Wearing of support hose? Avoiding crossing of legs? ______________________________________________________________________________________

Gastrointestinal System:

Yes

No

Changes/problems with appetite _____ Food intolerance _____ Dysphagia _____ Heartburn _____ Indigestion _____ Pain associated with eating _____ Other abdominal pain _____ Pyrosis _____ (esophageal and stomach burning sensation with sour eructation) Nausea and vomiting (character) _____ _____________________________________________________

_____ _____ _____ _____ _____ _____ _____ _____

Vomiting blood _____ History of: Ulcer _____ Liver Disease _____ Gallbladder Disease _____ Jaundice _____ Appendicitis _____ Colitis _____ Any flatulence _____ Frequency of bowel movements and any recent change ___________________________________________________________

_____

_____

_____ _____ _____ _____ _____ _____ _____

Stool characteristics ____________________________________________________________ Constipation Diarrhea Black stools Rectal Bleeding Hemorrhoids Fistula

_____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____

Health Promotion: Use of antacids or laxatives ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

Urinary System:

Yes

No

Frequency or urgency Nocturia (recent change) Dysuria Polyuria Oliguria Hesitancy or Straining Narrowed stream Cloudiness or Presence of Blood Urine colour ________________________________ Incontinence Hisory of: Kidney disease Kidney stones Urinary Tract Infections Prostate Disease Pain in flank, groin or suprapubic region, low back

_____ _____ _____ _____ _____ _____ _____ _____ Yes

_____ _____ _____ _____ _____ _____ _____ _____ No

_____

_____

_____ _____ _____ _____ _____

_____ _____ _____ _____ _____

Health Promotion: measures to avoid or treat urinary tract infections, use of Kegel exercises _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ __________________________________________________________

Male Genital System/Female Genital System: Male: Penile or testicular pain Sores or lesions Penile discharge Lumps Hernia

_____ _____ _____ _____ _____

_____ _____ _____ _____ _____

Health Promotion: perform testicular self-examination? How frequently? _____________________________________________________________________________________________ _____________________________________________________________________________________________ ________________________________________________________________________ Female: Menstrual history Age of menarche _____________________ Last menstrual period, cycle and duration _________________________________________ ____________________________________________________________________________________ Amenorrhea _____ _____ Menorrhagia _____ _____ Premenstrual pain or dysmenorrhea _____ _____ Yes

No

Intermenstrual spotting _____ _____ Vaginal itching _____ _____ Vaginal discharge _____ _____ Characteristics of vaginal discharge _________________________________________________ Age at menopause ___________________________ Menopausal signs or symptoms _____________________________________________________________________________________________ _______________________________________________________________________________ Postmenopausal bleeding _____ ______ Health Promotion: last gynecologic checkup and last Papanicoloaou test _____________________________________________________________________________________________ _______________________________________________________________________________ Breast and Axilla:

Yes

No

Any breast pain? Any evidence of a lump? Any nipple discharge? Any rash? History of breast disease? Surgery on the breasts? Any swelling under the arms?

_____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____

Health Promotion: Performs breast self exam; include frequency and method used. Date of last mammogram. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _________________________________________________________________ Sexual History: Current sexual activity____________________________________________________________________ Protective measures___________________________________________________________________ Level of sexual satisfaction of patient and partner_______________________________________ Dyspareunia (for female) Changes in erection or ejaculation (for male)

______ ______

______ ______

Any known or suspected contact with a partner who has a sexually transmitted disease(gonorrhea, herpes, chlamydia, venereal warts, AIDS or syphilis) ______ ______ Musculoskeletal System:

Yes

No

History of arthritis History of gout History of back pain or disc disease Joint pain

_____ _____ _____ _____

_____ _____ _____ _____

Stiffness Swelling Deformity Limitation of motion Noise with joint motion Muscle pain Muscle cramps Weakness Gait problems Problems with coordinated activities

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____

Health Promotion: How much walking per day? What is effect of limited range of motion on ADL’s such as grooming, feeding, toileting, dressing? Any mobility aids used? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _________________________________________________________________ Neurologic System

Yes

No

History of seizure disorder History of stroke History of fainting or blackouts

_____ _____ _____

_____ _____ _____

Motor function: Any weakness, tic or tremor Any paralysis or coordination problems

_____ _____

_____ _____

Sensory function: Any numbness and tingling(parathesia)

_____

_____

Cognitive function: Any recent memory disorder Any disorientation

_____ _____

_____ _____

Mental Status: Nervousness _____ _____ Mood change _____ _____ Depression _____ _____ History of mental health dysfunction or hallucinations _____ _____ Describe:_______________________________________________________________________

_____________________________________________________________________________ ____________________________________________________________

Hematologic System:

Yes

No

Any bleeding of skin or mucous membranes Any excessive bruising

_____ _____

_____ _____

Any swelling of lymph nodes

_____

_____

Any exposure to toxic agents or radiation Any blood transfusions or reactions

_____ _____

_____ _____

_____

_____

_____ _____ _____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____ _____ _____

Endocrine System: Any history of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia) History of thyroid disease Intolerance to heat or cold Change in skin texture or pigmentation Excessive sweating Abnormal hair distribution Any nervousness Tremor Need for hormone replacement Any change in relationship between appetite and weight

Health History (continued)

Personal/ Social History: Information regarding concerns of patient and influence of health problems on patient’s and family’s life Cultural background and practices: Birthplace

Position in family, Marital status (Social roles: Role in the family? How do you get along with family, friends, and coworkers: Support systems: Who do you go to for support for problems in family, at work, with your health, or with a personal problem? Amount of contact with spouse, siblings, parents, children, friends, organizations, workplace? Is time alone enjoyable or isolating?)

Religious preferences (Faith: Does religious faith or spirituality play an important role in your life? Influence: How does your religious faith or spirituality influence the way you think about your health or way you care for yourself? Community: Are you a part of any religious or spiritual community or congregation? Address: Would you like me (the health care professional) to address any religious or spiritual issues or concerns with you?) Self-Esteem, Self-Concept General life satisfaction, hobbies, interests Education: last grade completed, other significant training; Financial status: income adequate for lifestyle and/or health concerns; Value-belief system: religious practices and perception of personal strengths)

Personal Habits: (Tobacco: Do you smoke? cigarettes, pipe, chewing tobacco? At what age did you start? How many packs per day? How many years? If stopped, how long since stopped and the same questions asked for the time they were a smoker. If they have tried to quit, what did they try? How did it go? Which leads into smoking cessation discussion.) Alcohol: Do you drink alcohol? When was your last drink? How much do you drink each day, each week? If patient answers ‘no’ to drinking alcohol ask the reason for this decision. Any history of drinking alcohol? Any history of treatment? Involvement in recovery activities? History of family member with problem drinking? Street Drugs: Ask specifically about marijuana, cocaine, crack cocaine, amphetamines, and barbiturates. Indicate frequency of use and how use has affected work and family.)

Exercise: (Daily profile reflecting usual daily activities, ‘Tell me about a typical day’, ability to perform ADLs, IADL’s (independent or needs assistance); ability to tolerate activity;use of prostheses or mobility aids; leisure activities enjoyed; and exercise pattern (type, amount per day or week, warm-up session body’s response to exercise))

Sleep/Rest (Sleep patterns, daytime naps, any sleep aids used)

Nutrition/Elimination (Record the diet recall for 24-hour period. Is this menu typical? Who buys and prepares

food? Finances? Who is present at meal times? Food allergy or intolerance. Daily intake of caffeine (coffee, tea, cola drinks). Usual patterns for bowel elimination and urinating. Aids used for mobility or transfer in toileting. Any continence issues or use of laxatives.)

Coping and Stress Management (Kinds of stresses in life, especially in the last year, any change in lifestyle or any current

stress, methods tried to relieve stress and if these have been helpful.) Environment/Hazards Home, school, work.(Where do they live? With whom? Do they know their neighbours and the neighbourhood? Safety of the area? Adequate heat and utilities? Access to transportation? Involved in the community? Note environmental health, hazards in the workplace and the home? Use of seat belts? Geographic or occupational hazards (time spent abroad for travel or work)?)

Intimate Partner Violence (How are things at home? Do you feel safe? If patient responds to feeling unsafe then specific questions. Ever been emotionally or physically abused by your partner or someone important to you? Ever been hit, slapped, kicked, pushed or shoved or otherwise physically hurt by your partner or ex-partner? Partner ever forced you into having sex? Are you afraid of your partner or ex-partner?)

Occupational Health Work conditions and hours. Physical and mental strain; Work with any health hazards (asbestos, inhalants, chemicals, repetitive motion.) Protective devices used. Any programs at work designed to monitor your exposure? Any health problems you think are related to your job? What doyou like or dislike about your job?)

Perception of Own Health (How do you define health? View of own health now? What are your concerns? What do you expect will happen to your health future? Your health goals? What expectations do you have of the health care team?)

Reference Jarvis, C. (2008). Physical examination and health assessment (5th ed.). Philadelphia: W.B. Saunders.