Nursing Health History Form (Adult)
DEMOGRAPHIC DATA Types of Operation: ________________________________________________________
Name: Date of Admission: Obstetric/ Gynecologic
Address:
Obstetric history: Gravida ____ Para ____
Birthdate: Age: Civil Status: Sex: Menstrual history: ___________________
Methods of contraception: ____________
Psychiatric
Religion: Citizenship Educational Attainment:
Illness and time frame: ______________________
Diagnoses: _______________________________
Hospitalizations: __________________________
Occupation: Health Care Financing:
Treatment: _______________________________
Medical Diagnosis: Immunization History
Yes No
PART A
Tetanus
Reason for Current Admission:
Pneumonia
Influenza
MMR
History of Present Illness: Polio
Hepatitis B
Hib
Allergies
Symptoms/ Reaction Action Taken
Medicine
Food
Others
History of Family Illness
Name Age Relation to Health Status Cause of Death
Patient
Illness in the family similar to the patient’s:
Familial incidence of:
Rheumatic Fever Hypertension Tuberculosis Diabetes Mental Illness
Others: ___________________________________________________________________
PART B: Functional Health Pattern
1. Health perception- Health Management Pattern
A. How would you describe your usual Good
health status Fair
Poor
B. Are you satisfied with your usual Yes
health status? No. Sources of dissatisfaction?
_______________________________________
Past Medical History
C. Tobacco use? Current
CHILDHOOD ILLNESSES: Yes. # of packs/day? __ Date started: _______
No
Measles Rubella Chicken Pox Mumps Whooping cough Rheumatic
fever Scarlet Fever Polio Hepa A Hepa B Diarrhea Pneumonia Past
Others: ______________________________________ Yes. # of packs/day? __ Date started: _______
ADULT ILLNESSES: Date quit: _________
No
Medical Illnesses D. Alcohol use? Yes. How much and what kind? ___________
No
Diabetes Hypertension Hepatitis Asthma HIV
E. Street drug use? Yes. What and how much? ______________
Hospitalizations: ________________________________________
No
F. Any history of chronic diseases? Yes. Describe: ________________
Surgical
No
G. Have you sought any healthcare Yes. Why? __________________
Dates: _________________________
Indications: ____________________ assistance in the past year? No
Types of Operation: ________________________________________________________ H. Are you currently working? Yes. How would you rate your working
condition? Excellent __ Good __ Fair __
Dates: _________________________ Poor__ Describe any problem areas:
Indications: ____________________ __________________________
Types of Operation: ________________________________________________________ No
I. How would you rate living conditions Excellent
Dates: ________________________ at home? Good
Indications: ___________________ Fair
Nursing Health History Form (Adult)
Poor Color
Brown
J. Have you followed the routine Yes Black
prescribed for you? No. Why not? ______________________ Yellow
Clay colored
K. Did you think this prescribed routine Yes Bleeding with bowel movements
was the best for you? No. What would be better? ______________ No
Yes
L. Have you had any accidents/ injuries/ Yes. Describe: __________ C. History of constipation? Yes. When? _____
falls in the past year? No No
M. Have you had any problems with Yes. Describe: __________ D. Use of bowel movement aids Yes. Describe: ________
cuts healing? No (laxatives, suppositories, diet) No
N. In the past, easy to find way to follow Yes E. History of diarrhea? Yes. When? _____
suggestion for doctors or nurses? No No
O. If appropriate: What do you think F. History of incontinence? Yes
caused this illness? No
P. Action taken when symptoms
perceived? Related to increased abdominal pressure
Q. Results of action? (coughing, laughing, sneezing)
R. If appropriate: What is important to Yes
you while you are here? How can we No
be most helpful? G. History of recent travel Yes. Where?
S. Do you do (breast/testicular) self- Yes. How often? _______ No
examination? No H. Usual voiding pattern a. Frequency (times/day): ________________
2. Nutritional and Metabolic Pattern b. Urination
A. Any weight gain in the last 6 Yes. Amount: ______ Retention
months? No Frequency
Incontinent
B. Any weight loss in the last 6 months? Yes. Amount: ______
c. Presence of pain
No
Yes. Characteristics: _________________
C. Would you describe your appetite as Good
No
Fair
d. Presence of burning sensation
Poor. Describe: ______________
Yes
No
D. Do you have any food intolerances? Yes. What? ___________
e. Sensation of bladder spasms
No
Yes
E. Do you have any dietary restrictions? Yes. What? ___________ No
No
I. Perspiration Excessive
F. Describe an average day’s food intake for you (meals and snacks) Yes
No
Protein Carbohydrates Odor problems
Food Item Fat (grams) Energy (kcal)
(grams) (grams) Yes
No
4. Activity-Exercise Pattern:
A. Using the following Functional Level Feeding: ______
Classification, have the patient rate each Bathing/ Hygiene: _______
area of self-care: Dressing/grooming: _______
0= completely independent Toileting: ______
1= requires use of equipment/device Shopping: ______
2= requires help from another person for Bed mobility: _______
assistance, supervision, or teaching General mobility: _____
3= requires help from another person Home maintenance: ______
G. Describe an average day’s fluid and equipment or device
intake for you. 4= dependent, does not participate in
activity
B. Oxygen use at home? Yes. Describe: _______
H. Describe food likes and dislikes No
C. How many pillows do you use to
I. Would you like to Gain weight sleep on?
Lose weight D. Do you frequently experience Yes. Describe: _______
Neither fatigue? No
J. Any problems with Nausea E. How many stairs can you climb
Yes. Describe: _______ without experiencing any difficulty?
No F. How far can you walk without
Vomiting experiencing any difficulty?
Yes. Describe: ______ G. Any history of falls? Yes. How often? ______
No No
Swallowing H. Has assistance at home for care of Yes. Who? ______
Yes. Describe: ______ self and maintenance of home? No
No I. Any complaints of weakness or lack Yes. Describe: ______
Chewing of energy? No
Yes. Describe: ______ J. Any difficulties in maintaining Yes. Describe: ______
No activities of daily living? No
Indigestion K. Any problems with concentration? Yes. Describe: ______
Yes. Describe: ______ No
No L. If in wheelchair, do you have any Yes. Describe: ______
K. Skin Problems Yes. Describe: _____ problems manipulating the No
No wheelchair?
L. Dental Problems Yes. Describe: _____ M. Can you move yourself from site to Yes. Describe: ______
No site with no problems? No
3. Elimination Pattern 5. Sleep-Rest Pattern
A. What is your usual frequency of Diarrhea A. Usual sleep habits Hours/ night: ____
bowel movements Constipation Naps
Ostomy Yes. AM or PM? ____
Normal No
Feel rested
B. Character of stool: Consistency Yes
Hard No. Describe: ________
Soft
Liquid B. Any problems Difficulty going to sleep
Nursing Health History Form (Adult)
Yes Yes. Children? __ Yes. # of children: _____
No __ No
Awakening during the night No
Yes
No Name of children Age Premature/ Full-term
Early awakening
Yes
No
Insomnia
Yes. Describe: _________
No
C. Methods used to promote sleep Medication
Yes. What? _________
C. Any family problems you have Not applicable
No
difficulty handling? No difficulty with
Warm fluids
Average
Yes. What? _________
Some difficulty with. Describe: ________
No
Relaxation technique
D. Any losses (physical, Yes. Describe: ________
Yes
psychological, social) in the past No
No
year?
6. Cognitive-Perceptual pattern
E. How is the patient handling this
A. Hearing difficulty Yes. Describe: _________
loss at this time?
No
F. Do you believe this admission will Yes. Describe: _________
B. Vision Wear glasses
result in any type of loss? No
Yes. Last checked: _______
G. Family depends on you for Yes. How are you managing? _________
No
things? No
C. Memory Change in memory lately
H. If appropriate: How do
Yes. Why? ________
family/others feel about your
No
illness/hospitalization?
D. Pain Location (have the patient point to area): ______
Intensity (have the patient rank on scale): ______ I. Belong to Social groups
Yes
Radiation
No
Yes. Where? ________
Close friends
No
Yes
Timing: __________
No
Duration: ________
What do you do to relieve pain at home? _______ J. Feel lonely Yes. Describe: _________
When did the pain begin? _____________ No
K. How would you rate your comfort Comfortable
E. Decision-making Final decision-making in social situations? Uncomfortable
Easy L. How would you rate your usual Very active
Moderately easy social activities? Active
Moderately difficult Limited
Difficult None
Inclined to make decision M. Things generally go well for you Yes. Describe: _________
Yes. Describe: _________ at work? No
No 9. Sexuality-Reproductive pattern
F. Knowledge level Can define what current problem is? A. Females Date of LMP _____
Yes Any pregnancies?
No Para: ____
Can restate current therapeutic regimen? Gravida: ____
Yes Menopause
No Yes. Year: ______
7.Self-perception and Self-concept Pattern No
A. My usual view of myself is Positive Use of birth control measures
Neutral Yes. Type: _____
Somewhat negative No
B. Changes in your body or the things Yes. Describe: _______ N/A
you can do No Any history of vaginal discharge, bleeding, lesion?
Yes. Describe: _______
C. Are these problematic for you? Yes. Describe: _______
No
No
Pap smear annually
D. Changes in way you feel about Yes. Describe: _______
Yes. Date of last Pap Smear: ________
yourself or your body (since illness No
No
started)
Date of last mammogram: ________
E. Find things frequently make you Angry
History of STF (sexually transmitted disease)
Yes. Describe: _______
Yes. Describe: _______
No No
Annoyed
B. If admission secondary to rape Is the patient describing numerous physical
Yes. Describe: _______
symptoms?
No
Yes. Describe: ________
Fearful
No
Yes. Describe: _______
Is the patient exhibiting numerous emotional
No
reactions?
Anxious
Yes. Describe: ________
Yes. Describe: _______
No
No
What has been your primary coping mechanism to
Depressed
handle this rape episode? ____________
Yes. Describe: _______
Have you talked to persons from rape crisis center?
No
Yes. Describe: _________
F. Ever feel you lose hope? Yes. Describe: _______ No
No
If No, does the patient want you to contact them?
G. Not able to control things in life Yes. Describe: _______ Yes
No No
If Yes, was this contact of assistance?
8. Role-relationship Pattern Yes. Describe: _______
A. Does the patient live alone? Yes No
No. With whom? _______________________ C. Male Any history of prostate problems?
Yes. Describe: ______
B.Is the patient married? No
Any history of penile discharge, bleeding, lesions?
Nursing Health History Form (Adult)
Yes. Describe: ______
No
Date of last prostate exam: _________________
History of STD (sexually transmitted disease)
Yes. Describe: ________
No
D. Both Are you experiencing any problems in sexual
functioning?
Yes. Describe: _________
No
Are you satisfied with your sexual relationship?
Yes. Describe: _________
No
Do you believe this admission will have any impact
on sexual functioning?
Yes. Describe: _________
No
10. Coping-Stress Tolerance Pattern
A. Have you experienced any Yes. Describe: ________
stressful or traumatic events in No
the past year in addition to this
admission?
B. How would you rate your usual Good
handling of stress? Average
Poor
C. What is the primary way to deal
with stress or problems?
D. Tense a lot of time? Yes. What helps? ________
No
E. When big problems occur in your
life, how do you handle them?
F. Most of the time, is this way Yes
successful? No
11. Value-Belief Pattern
A. Satisfied with the way your life Yes. Comments: ___________
has been developing? No
B. Will this admission interfere with Yes. How? _________
your plans for the future? No
C. Religion
D. Will this admission interfere with Yes. How? _________
your spiritual or religious No
practices?
E. Any religious restrictions to care Yes. Describe: _________
(diet, blood transfusion)? No
F. Would you like to have you Yes. Who: __________
(pastor, rabbi, hospital chaplain) No
contacted to visit you?
Have your religious beliefs helped Yes. Comments: __________
you deal with the problems in the No
past?
Reference:
Newfield, S.A., Hinz, M.D., Scott-Tilley, D.,
Sridaromont, K.L., & Maramba, P.J. (2007).
Cox’s clinical applications of nursing diagnosis:
Adult, child, women’s, mental health, gerontic, and
home health considerations (5th ed.). Philadelphia,
PA: F. A. Davis Company.
Nursing Health History Form (Adult)
