Golden Gate Colleges P. Prieto ST., Batangas City: College of Nursing

GOLDEN GATE COLLEGES

P. Prieto St., Batangas City

COLLEGE OF NURSING

COMPLETE HEALTH HISTORY
A. Biographical Data
1. Name
2 Address
3 Phone
4. Gender
5. Birth date
6. Place of birth
7. Race or ethnic background
8. Educational Level
9. Occupation
B . History of Present Health Concern

1. Character (How does it feel, look, smell, sound, etc.?)
2 Onset (When did it begin; is it better, worse, or the
same since it began?)
3. Location (Where is it? Does it radiate?)
4. Duration (How long it lasts? Does it recur?)
5. Severity (How bad is it on a scale of 1 [barely noticeable] to 10 [worst pain ever
experienced]?)
6. Pattern (What makes it better? What makes it worse?)
7. Associated factors (What other symptoms do you have
with it? Will you be able to continue doing your
work or other activities [leisure or exercise]?)
C. Past Health History

1. Problems at birth
2 Childhood Illnesses
3. Immunizations to date
4. Adult illnesses (physical, emotional, mental)
5. Surgeries
6. Accidents
7. Prolonged pain or pain patterns
8. Allergies
D. Family Health History

Age of parents (Living? Deceased date?)
Parent illnesses
Grandparent’s Illnesses
Aunt’s and uncle’s age and illnesses
Children’s age and illnesses or handicaps
E. Lifestyle & Health Practices

1. Description of a typical day (AM to PM)
COLLEGE OF NURSING
2. 24-hour dietary intake (foods and fluids)
3. Who purchases and prepares meals
4. Activities on a typical day
5. Exercise habits and patterns
6. Sleep and rest habits and patterns
7. Use of medications and other substances (caffeine,
nicotine, alcohol, recreational drugs)
8. Self concept
9. Self-care responsibilities
10. Social activities for fun and relaxation
11. Social activities contributing to society
12. Relationships with family, significant others, and pets
13 Values, religious affiliation, spirituality
14 Past, current, and future plans for education
15. Type of work, level of job satisfaction, work stressors
16. Finances
17. Stressors in life, coping strategies used
18. Residency, type of environment, neighborhood, environmental Risks
Review of Systems (ROS) for Current Health Problems

1 Skin, hair, and nails: Skin color, temperature, condition, excessive sweating,
rashes, lesions, balding, dandruff, condition of nails
2. Head and neck: Headache, swelling, stiffness of neck, difficulty swallowing, sore
throat, enlarged lymph nodes
3 Eyes: Vision, eye infections, redness, excessive tearing, halos around lights,
blurring, loss of side vision, moving black spots/specks in visual fields, flashing lights,
double vision, and eye pain
4. Ears: Hearing, ringing or buzzing, earaches, drainage from ears, dizziness,
exposure to loud noises
5. Mouth, throat, nose, and sinuses: Condition of teeth and gums; sore throats;
mouth lesions; hoarseness; rhinorrhea; nasal obstruction; frequent colds; sneezing
or itching of eyes, ears, nose, or throat; nose bleeds; snoring
6. Thorax and lungs: Difficulty breathing, wheezing, pain, shortness of breath during
routine activity, orthopnea, cough or sputum, hemoptysis, respiratory infections
7. Breasts and regional lymphatics: Lumps or discharge from nipples, dimpling or
changes in breast size, swollen or tender lymph nodes in axilla
8. Heart and neck vessels: Last blood pressure, ECG tracing or findings, chest pain
or pressure, palpitations, edema
9. Peripheral vascular: Swelling, or edema, of legs and feet; pain; cramping; sores
on legs; color or texture changes on the legs or feet
10. Abdomen: Indigestion, difficulty swallowing, nausea, vomiting, abdominal pain,

gas, jaundice, hernias
11. Male genitalia: Excessive or painful urination, frequency or difficulty starting and
maintaining urinary stream, leaking of urine, blood noted in urine, sexual problems,
COLLEGE OF NURSING
perineal lesions, penile drainage, pain or swelling in scrotum, difficulty achieving an
erection and/or difficulty ejaculating, exposure to sexually transmitted infections
12. Female genitalia: Sexual problems; sexually transmitted diseases; voiding
problems (e.g., dribbling, incontinence); reproductive data such as age at
menarche, menstruation (length and regularity of cycle), pregnancies, and type of or
problems with delivery, abortions, pelvic pain, birth control, menopause (date or year
of last menstrual period), and use of hormone replacement therapy
13. Anus, rectum, and prostate: Bowel habits, pain with defecation, hemorrhoids,
blood in stool, constipation, diarrhea
14. Musculoskeletal: Swelling, redness, pain, stiffness of joints, ability to perform
activities of daily living, muscle strength
15. Neurologic: General mood, behavior, depression, anger, concussions,
headaches, loss of strength or sensation, coordination, difficulty speaking,
memory problems, strange thoughts and/or actions, difficulty learning
SAMPLE INTERVIEW QUESTIONS
History of Present Health Concern
1. “When did you first notice the pain in your back?
2 How long have you experienced it? Has it become worse, better, or stayed the
same since it first occurred?”
3. “What does the pain feel like? Where does it hurt the most? Does it radiate or go
to any other part of your body? How intense is the pain? Rate the pain on a scale of
1 to 10 with 1 being barely noticeable and 10 being the worst pain you have ever
experienced. Do you have any other problems that seem related to this back pain?”
4. “What do you think caused this problem to start?”
5. “What makes your back hurt more? What makes it feel better? Have you tried any
treatments to relieve the pain such as aspirin or acetaminophen (Tylenol) or anything
else?”
6. “How does the pain affect your life and daily activities?”
7. “What do you think will happen with this problem? Do you expect to get well?
What about your job? Do you think you will be able to continue working?
Past Health History
1 Can you tell me how your mother described your birth? Were there any problems?
As far as you know, did you progress normally as you grew to adulthood? Were
there any problems that your family told you about or that you experienced?”
COLLEGE OF NURSING
2 . “What diseases did you have as a child such as measles or mumps? What
immunizations did you get and are you up to date now?
3 “Do you have any chronic illnesses? If so, when was it diagnosed? How is it
treated? How satisfied have you been with the treatment?”
4. “What illnesses or allergies have you had? How were the illnesses treated?”
5. “Have you ever been pregnant and delivered a baby? How many times have you
been pregnant/ delivered?”
6. “Have you ever been hospitalized or had surgery? If so, when? What were you
hospitalized for or what type of surgery did you have? Were there any
complications?”
7. “Have you experienced any accidents or injuries? Please describe them.”
8. “Have you experienced pain in any part of your body? Please describe the pain.”
9. “Have you ever been diagnosed with/treated for emotional or mental problems? If
so, please describe their nature and any treatment received. Describe your level of
satisfaction with the treatment.”
D. Family Health History
E. Lifestyle & Health Practices

1. Description of a typical day (AM to PM)
 “Please tell me what an average or typical day is for you. Start with
awakening in the morning and continue until bedtime.”
 Encourage the client to discuss a usual day, which, for most people,
includes work or school. If the client gives minimal information, additional specific
questions may be asked to draw out more details.
2. Nutrition and Weight Management

2.1“What do you usually eat during a typical day? Please tell me the kinds of foods
you prefer, how often you eat throughout the day, and how much you eat.”
2.2 “Do you eat out at restaurants frequently?”
2.3“Do you eat only when hungry? Do you eat because of boredom, habit, anxiety,
depression?”
2.4 “Who buys and prepares the food you eat?”
2.5 “Where do you eat your meals?”
2.6 “How much and what types of fluids do you drink?”
3. Activity Level and Exercise

3.1 “What is your daily pattern of activity?”
3.2 “Do you follow a regular exercise plan? What types of exercise do you do?”
COLLEGE OF NURSING
3.3 “Are there any reasons why you cannot follow a moderately strenuous exercise
program?”
3.4 “What do you do for leisure and recreation?”
3.5 “Do your leisure and recreational activities include exercise?”
4. Sleep and Rest

4.1 Tell me about your sleeping patterns.”
4.2 “Do you have trouble falling asleep or staying asleep?”
4.3 “How much sleep do you get each night?”
4.4 “Do you feel rested when you awaken?”
4.5 “Do you nap during the day? How often and for how long?”
4.6 “What do you do to help you fall asleep?”
5. Medication and Substance Use

5.1 “What medications have you used in the recent past and currently, both those
that your doctor prescribed and those you can buy over the counter at a drug or
grocery store? For what purpose did you take the medication? How much (dose) and
how often did you take the medication?”
5.2 “How much beer, wine, or other alcohol do you drink on the average?”
5.3 “Do you drink coffee or other beverages containing caffeine (e.g., cola)?” If so,
how much and how often?
5.4 “Do you now or have you ever smoked cigarettes or used any other form of
nicotine? How long have you been smoking/did you smoke?
5.5 How many packs per week? Tell me about any efforts to quit.”
5.6 “Have you ever taken any medication not prescribed by your healthcare
provider? If so, when, what type, how much, and why?”
5.7 “Have you ever used, or do you now use, recreational drugs? Describe any
Usage.”
5.8 “Do you take vitamins or herbal supplements? If so, what?”
6. Self-Concept and Self-Care Responsibilities

6.1 “What do you do for fun and relaxation?”
6.2 “With whom do you socialize most frequently?”
6.3 “Are you involved in any community activities?”
6.4 “How do you feel about your community?”
6.5 “Do you think that you have enough time to socialize?”
6.6 “What do you see as your contribution to society?”
7. Relationships
7.1 “Who is (are) the most important person(s) in your life? Describe your
relationship with that person.”
7.2 “What was it like growing up in your family?”
7.3 “What is your relationship like with your spouse?”
7.4 “What is your relationship like with your children?”
7.5 “Describe any relationships you have with significant others.”
7.6 “Do you get along with your in-laws?”
7.7 “Are you close to your extended family?”
COLLEGE OF NURSING
7.8 “Do you have any pets?”
8. Social Activities
8.1 “What is your role in your family? Is it an important role?”
8.2 “Are you satisfied with your current sexual relationships? Have there been any
recent changes?”
9. Values and Belief System

9.1 “What is most important to you in life?”
9.2 “What do you hope to accomplish in your life?”
9.3 “Do you have a religious affiliation? Is this important to you?”
9.4 “Is a relationship with God (or another higher power) an important part of your
life?”
9.5 “What gives you strength and hope?”
10. Education and Work

10.1 “Tell me about your experiences in school or about your education.”
10.2 “Are you satisfied with the level of education you have? Do you have future
educational plans?”
10.3 “What can you tell me about your work? What are your responsibilities at
work?”
10.4 “Do you enjoy your work?”
10.5 “How do you feel about your coworkers?”
10.6 “What kind of stress do you have that is work related? Any major problems?”
10.7 “Who is the main provider of financial support in your family?”
10.8 “Does your current income meet your needs?”
11. Stress Levels and Coping Styles

11.1 “What types of things make you angry?”
11.2 “How would you describe your stress level?”
11.3 “How do you manage anger or stress?”
11.4 “What do you see as the greatest stressors in your life?”
11.5 “Where do you usually turn for help in a time
of crisis?”
12. Environment
12.1 “What risks are you aware of in your environment such as in your home,
neighborhood, on
the job, or any other activities in which you
participate?”
12.2 “What types of precautions do you take, if any,
when playing contact sports, using harsh chemicals or paint, or operating
machinery?”
12.3 “Do you believe you are ever in danger of becoming
a victim of violence? Explain.”
,
COLLEGE OF NURSING
Case Study Components
Anatomy and Physiology

History Taking, Physical Exam
Pathophysiology
Lab/Diagnostic Tests
Management
a. Medical (Dialysis)
b. Pharmacology
NCP (3)
High
Medium
Low

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GOLDEN GATE COLLEGES

P. Prieto St., Batangas City

COMPLETE HEALTH HISTORY

B . History of Present Health Concern

C. Past Health History

D. Family Health History

E. Lifestyle & Health Practices

Review of Systems (ROS) for Current Health Problems

10. Abdomen: Indigestion, difficulty swallowing, nausea, vomiting, abdominal pain,

SAMPLE INTERVIEW QUESTIONS

History of Present Health Concern

1. “When did you first notice the pain in your back?

4. “What do you think caused this problem to start?”

Past Health History

7. “Have you experienced any accidents or injuries? Please describe them.”

D. Family Health History

E. Lifestyle & Health Practices

2. Nutrition and Weight Management

3. Activity Level and Exercise

4. Sleep and Rest

5. Medication and Substance Use

6. Self-Concept and Self-Care Responsibilities

9. Values and Belief System

10. Education and Work

11. Stress Levels and Coping Styles

Case Study Components

Anatomy and Physiology

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