NURSING HEALTH HISTORY
(A Format)
A. Demographic (Biographical Data) (Do not omit the following labels in your output)
1. Client’s initials:
2. Gender:
3. Age, Birthdate and Birthplace:
4. Marital (Civil) Status:
5. Nationality:
6. Religion:
7. Address and Telephone Number:
8. Educational Background:
9. Occupation (usual and present):
10. Usual Source of Medical Care:
B. Source and Reliability of Information
(Should be in narrative form; you should describe specifically the patient’s attitude during the
assessment and their capability of giving accurate and reliable responses)
Sample Statements:
The patient was competent to provide information. She was able to speak clearly; conscious
and coherent; oriented to time, place and person.
Other Possibilities:
The patient was too weak to provide information; data had to be obtained and validated
from the relative.
The patient’s chart was also included as a secondary source of information
C. Reasons for Seeking Care or Chief Complaints (Preferably Top 3)
(The heading for this section can change according to the data you will obtain, if you get health
promotive statements, use only “Reasons for Seeking Care,” if disease-related or complaints, use
“Chief Complaints,” if it is a combination, retain the title above then change “or” to “and”)
Sample Statements: (SHOULD BE IN DIRECT QUOTATIONS)
1. “Chest pain for 2 hours”
2. “Earache and restlessness all night”
3. “Physical examination for work purposes”
4. “Wants to start jogging and needs check-up”
D. History of Present Illness or Present Health
Well person General state of health
Ill person Chronological story record of how the illness came about
8 Critical Characteristics: (integrate in one whole narrative)
1. Timing (frequency/onset/duration)
2. Location (the primary area where the symptom occurs or originates)
3. Quality (Character) – (describes the way the cc feels to the patient)
4. Quantity / Severity (volume, number, or extent of the cc)
5. Setting (physical environment, mental state, or activity wherein the symptoms occur)
6. Associated Phenomena / Factors (signs and symptoms that accompany the cc)
7. Aggravating and Alleviating Factors (factors that worsen or decrease the severity of
the cc, respectively)
8. Client’s Perception (how the client thinks & feels about the illness)
E. Past Medical History or Past Health (narrative form per category)
a. Pediatric / Childhood / Adult Illnesses (Indicate age or date (year) of occurrence)
b. Injuries or Accidents (Indicate age or date (year) of occurrence)
c. Hospitalization and Operations (Indicate age or date (year) of occurrence)
d. Reproductive History (for females – include menstrual history (age at menarche, LMP,
cycle and duration), also include OB history (if pregnant: OB score), complications of
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pregnancy and birth control methods used, age at onset of secondary sex
characterisitics, etc.) (for males: include age at onset of secondary sex characteristics,
and any problems or difficulties encountered, etc)
e. Immunization (put a check mark on the following that is applicable to your client)
BCG: / / At Birth / / School Entrance
DPT: / / 1 Dose / / 2nd dose
st
/ /3rd dose
st nd
OPV: / / 1 Dose / / 2 dose / /3rd dose
AMV: / /
TT: / / 1st Dose / / 2nd dose / /3rd dose / / 4th dose / / 5th dose
st nd rd
HBV: / / 1 Dose / / 2 dose / /3 dose
Others: (Varicella Vaccine? Influenza Vaccine? Pneumococcal Vaccine? etc.)
f. Allergies (put a check mark on the following that is applicable to your client, if the
patient has no allergies, just simply indicate “NONE”)
/ / Food, please specify: _________________________
/ / Drugs or medications, please specify: ________________________
/ / Chemicals, please specify: _________________________
/ / Other environmental allergens, please specify: _________________________
(If there are allergic reactions to any of the allergens listed above, indicate the kind of
reaction the patient experiences and intervention used to alleviate the manifestations in a
narrative format)
g. Medications (In a narrative format, determine the medications taken by your client
prior hospital admission (both prescribed and OTC); indicate the generic and brand
name, and if possible, dosage and frequency of intake; do not forget to include the
drug’s use or indication based on the patient’s description)
F. Family History (Includes the GENOGRAM; with brief explanation and analysis)
(Include age, present condition, cause of death)
(Place the “Legend” under the genogram)
(If in case the client cannot provide or remember the information, just put “UNRECALLED AGE,”
“UNRECALLED ILLNESS,” or “UNRECALLED CAUSE OF DEATH,” whichever are applicable)
Use the following legend:
Male Female Male Patient Female Patient Deceased
G. Socio-Economic History
(Include a brief explanation of significant data)
(Include the members of the family currently living with the client in the same household; if the
client receives financial support from other people, also include them here – just be particular
with the relationship of that person to the client)
FAMILY MEMBER /
OCCUPATION / MONTHLY INCOME (optional)
RELATIONSHIP TO
SOURCE OF INCOME
PATIENT
(Include the patient if (Write “Not Disclosed” if members
he/she is an income prefer confidentiality of income, or
earner) N/A if not applicable to the family
member)
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H. Psychosocial Assessment
(Specific for the current developmental stage of the client)
(Use Erik Erikson’s Psychosocial Development Theory)
Example:
Patient’s Age: 53 years old
Developmental Stage: Middle Adulthood
Developmental Task: Generativity vs. Stagnation
(1st paragraph - textual description of the developmental stage and task)
(2nd paragraph - synthesis or analysis of the patient)
I. Functional Assessment
(Use Gordon’s Functional Health Pattern)
(The narrative per item should answer ALL the questions applicable based on the interview guide)
1. Health-Perception-Health Management Pattern
2. Nutritional-Metabolic Pattern
3. Elimination Pattern
4. Activity-Exercise Pattern
5. Sleep-Rest Pattern
6. Cognitive-Perceptual Pattern
7. Self-Perception-Self Concept Pattern
8. Role Relationship Pattern
9. Sexuality-Reproductive Pattern
10. Coping-Stress Tolerance Pattern
11. Value-Belief Pattern
J. Review of Systems
SYSTEM R.O.S. (Direct Quotations FROM THE PATIENTS ONLY)
1. General
2. Integument (Skin, Hair, Nails)
3. Head
4. Eyes
5. Ears
6. Nose and Sinuses
7. Mouth and Throat
8. Neck
9. Breast and Axilla
10. Respiratory
11. Cardiac
12. Gastrointestinal
13. Urinary
14. Genitalia
15. Peripheral Vascular
16. Musculoskeletal
17. Neurologic
18. Hematologic
19. Endocrine
20. Psychiatric
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FUNCTIONAL ASSESSMENT
(Interview Guide)
1. Health-Perception-Health Management Pattern
Describes the client’s perceived patterns of health & well- being & how their health is
managed.
person’s description of his current health
activities that the person does to improve or maintain his health
person’s knowledge about links between lifestyle choices and health
extent of person’s problem on financing health care, if any
person’s knowledge of the names of current medications he is taking and their
purpose/s
activities that the person does to prevent problems related to allergies, if any
person’s knowledge about medical problems in the family
any important illnesses or injuries in this person’s life
2. Nutritional-Metabolic Pattern
Describes the consumption relative to metabolic need & nutrient supply; includes
pattern of food & fluid consumption, condition of skin, hair, nails & mucous
membranes, body temperature, height & weight.
person’s nourishment
person’s food choices in comparison with recommended food intake
any disease that affects nutritional-metabolic function
3. Elimination Pattern
Describes the pattern of excretory function (bowel, bladder & skin); includes
individual’s daily pattern, changes or disturbances & methods used to control
excretion.
person’s excretory pattern
any disease of the digestive system, urinary system or skin
4. Activity-Exercise Pattern
Describes the pattern of exercise, activity, leisure, & recreation; includes activities of
daily living, type and quality of exercise & factors affecting activity pattern (such as
neuromuscular, respiratory, & circulatory).
person’s description of his weekly pattern of activities, leisure, exercise and
recreation
any disease that affects his cardio-respiratory and/or musculoskeletal systems
5. Sleep-Rest Pattern
Describes the pattern of sleep, rest & relaxation and any aids to change those
patterns.
description of the person’s sleep-wake cycle
person’s physical appearance (rested or relaxed?)
6. Cognitive-Perceptual Pattern
Describes the sensory-perceptual and cognitive patterns; includes adequacy of
sensory modes (vision, hearing, touch, taste and smell), reports of pain perception,
and cognitive functional abilities.
any sensory deficit and if corrected
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person’s ability to express himself clearly and logically
person’s education
any disease that affects mental or sensory function
person’s pain description & causes, if any
7. Self-Perception-Self Concept Pattern
Describes how persons perceive themselves; their capabilities, body image and
feelings.
anything unusual about the person’s appearance (based on his own description)
if person is comfortable with his appearance
description of the person’s feeling state
8. Role Relationship Pattern
Describes the pattern of role engagements and relationships; includes perception of
major roles & responsibilities in current life situation.
person’s description of his various roles in life
positive role models of his roles, if any
important relationships at present
any big changes in role or relationship
9. Sexuality-Reproductive Pattern
Describes the pattern of satisfaction or dissatisfaction with sexuality; includes
female’s reproductive state.
person’s satisfaction with his situation related to sexuality
How have the person’s plans and experiences matched regarding having
children?
any disease/dysfunction of the reproductive system
10. Coping-Stress Tolerance Pattern
Describes the general coping pattern and effectiveness of coping skills in stress
tolerance.
person’s means/actions of coping with problems
if coping actions help or make things worse
any treatment/therapy for emotional distress (if any)
11. Value-Belief Pattern
Describes the pattern of values, goals, or beliefs (including spiritual beliefs) that
guide lifestyle choices and decisions.
principles that the person learned as a child which are still important to him
person’s identification with any cultural, ethnic, religious, regional or other
groups
support systems that the person finds significant
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REVIEW OF SYSTEMS
(A Guide)
Note: Some symptom/s findings may appear in more than one system, answers only need to be
recorded once
GENERAL:
Present weight (gain, loss, period of time, by diet or other factors), fatigue, weakness or malaise,
fevel, chill, sweats or night sweats)
INTEGUMENT:
Skin: History of skin disease (eczema, psoriasis, hives, pigment or color change in mole, excessive
dryness or moisture pruritus, excessive bruising, rashes or lesions, include amount of sun exposure
and method of self-care)
Hair: Recent loss, changes in texture
Nails: Change in shape, color, or brittleness
HEAD:
Any unusual frequent or severe headache, any head injury, dizziness, vertigo
EYES:
Changes in vision, use of glasses or contact lenses (When was it first used and for how long?), eye
pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights,
glaucoma, cataracts and last eye examination
EARS:
Otorrhea, tinnitus, history of infections, vertigo, ear pain, hearing loss and how it affects life,
hearing aid use, any exposure to environmental noise and method of cleaning ears
NOSE AND SINUSES:
Frequent colds, nasal stuffiness, discharge or itching, nosebleeds, sinus trouble
MOUTH AND THROAT:
Mouth pain, frequent sore throat, bleeding gums, toothache lesion on lips/tongue or mucosa,
dysphagia, hoarseness, or voice change, tonsillectomy, altered taste, pattern of daily dental care,
use of prosthesis (dentures), and last dental check-up
NECK:
Pain, stiffness, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter
BREAST AND AXILLA:
Pain, lump, nipple-discharge, rash, history of breast disease, any surgery of the breast,
performance of BSE including its frequency and method used
RESPIRATORY:
History of lung disease (emphysema, pneumonia, asthma, bronchitis, TB, etc.), chest pain upon
breathing, wheezing, noisy breathing, cough, sputum (color, amount), hemoptysis, toxin or
pollution exposure as well as last CXR study
CARDIAC:
Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of
exertion: ex. walking one flight of stairs, walking from chair to bath, or just talking), orthopnea,
paroxysmal nocturnal dyspnea, edema, history of heart murmur, hypertension, cardiovascular
diseases, anemia, and date of last ECG or other heart tests.
GASTROINTESTINAL:
Appetite, food intolerance, dysphagia, indigestion, other abdominal pain, pyrosis, nausea and
vomiting (character), hematemesis, history of abdominal disease (ulcer, liver, gallbladder,
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jaundice, appendicitis, colitis, flatulence, bowel frequency, any present changes, stool
characteristics, constipation, diarrhea, black-tarry stolls, rectal bleeding, rectal conditions
(hemorrhoids, fistula), use of antacids and laxatives, also include diet history and substance use
URINARY:
Frequency, urgency, nocturia, dysuria, polyuria or oliguria, hesitancy or straining, narrowed
stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease
(kidney disease, kidney stones, UTI, prostate), pain in the flank, groin, suprapubic region, or low
back, also include exercise after childbirth
GENITALIA:
Male: Penis or testicular exam, pain, sore or lesions, penile discharge, lumps, hernia
Female: Any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual
spotting, vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or
symptoms, post menstrual bleeding, last gynecological check-up, last papanicolau smear, also
include OB history (if married: OB score), complications of pregnancy, birth control methods used
and operations undergone
PERIPHERAL VASCULAR:
Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration of hands or
feet (bluish, reddish, pallor, mottling, association with position, especially around feet and ankles),
varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers
Does the occupation of the client involve long-term sitting or standing? Does the client avoid
crossing legs at the knees? Does the client wear support hose?
MUSCULOSKELETAL:
Joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, noise
with joint motion
Muscles: Pain, cramps, weakness, gait problems or problems with coordinated activities
Back: Pain (location and radiation to extremities) stiffness, limitation of motion, or history of back
pain or disease
NEUROLOGIC:
History of seizure disorder and stroke
Sensory function: Memory disorders (recent or distant, disorientation)
Motor function: tics or tremors, paresis – weakness, fainting, blackouts
HEMATOLOGIC:
Bleeding tendency of the skin or mucous membranes, excessive bruising, exposure to toxic agents
or radiation, blood transfusions, and reactions
ENDOCRINE:
History of diabetic symptom (polydipsia, polyphagia, polyuria) history of thyroid disease,
intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, abnormal
hair distribution, nervousness, tremors, and need for hormone therapy
PSYCHIATRIC:
Nervousness, mood change, depression, history of mental dysfunction or hallucinations
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