Complete Health History

■ Biographic 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. Chief complaint should not be confused with medical diagnosis (e.g., Pt is complaining of nausea and vomiting and is later diagnosed to be having an MI; chief complaint is nausea and vomiting and is documented as such even though the medical diagnosis may be evolving MI).

■ Past Health History: Record childhood illnesses, surgical procedures, 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 taken only when needed (p.r.n). Note: p.r.n. medications may not be used very often and are likely to have an outdated expiration date. Remind Pts to replace outdated medications. Inquire about OTC drugs, vitamins, herbs, alternative regimens, and use of recreational drugs or alcohol.

■ Allergies: Do not limit to drug allergies. Include allergies to food, insects, animals, seasonal changes, chemicals, latex, adhesives, etc. Try to differentiate between allergy and 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/relationships, sexuality patterns, social support, and stress coping mechanisms.

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

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

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

■ Focused assessment: Priority of assessment is dictated by Pt’s chief complaint.