Complete Health History

Complete Health History

■ Biographical Data: Record Pt’s name, age, and date of birth, gender, race, ethnicity, nationality, religion, marital status, children, level of education, job, and advance directives.

■ Chief Complaint (subjective): Symptom analysis for chief complaint. This is what the Pt tells you. The chief complaint should not be confused with the medical diagnosis (e.g., a Pt is complaining of nausea and vomiting and is later diagnosed to be having a myocardial infarction [MI]. The chief complaint is nausea and vomiting and is documented as such even though the medical diagnosis may be an evolving MI).

■ Past Health History: Record childhood illnesses, surgeries, hospitalizations, serious injuries, medical problems, immunization, and recent travel or military service.

■ Medications: Ask about prescription medications taken on a regular basis as well as those medications that are taken only when needed (prn). Note: prn medications may not be used very often and are likely to have an outdated expiration date. Remind Pts to replace outdated medications. Inquire about over-the-counter (OTC) drugs, vitamins, herbs, and alternative regimens.

■ Allergies: Do not limit to drug allergies. Include allergies to food, insects, animals, seasonal changes, chemicals, latex, adhesives, etc. Try to differentiate between an allergy and a sensitivity, but always err on the side of safety if unsure. Determine type of allergic reaction (itching, hives, dyspnea, etc.).

■ Family History: Includes health status of spouse/significant other, children, siblings, parents, aunts, uncles, and grandparents. If deceased, obtain age and cause of death.

■ Social History: Assess health practices and beliefs, typical day, nutritional patterns, activity/exercise patterns, recreation, pets, hobbies, sleep/rest patterns, personal habits, occupational health patterns, socioeconomic status, roles/relationship, sexuality patterns, social support, and stress coping mechanisms.

■ Physical Assessment (objective):There are two methods for performing a complete physical assessment.

■ Head-to-toe: More complete, it assesses each region of the body (e.g., head and neck) before moving on to the next.

■ Systems Assessment: More focused, it assesses each body system (e.g., cardiovascular) before moving on to the next.