Health History Form On A Family Member/Friend
Health History Form On A Family Member/Friend
NUR2092 WRITE-UP—HEALTH HISTORYClassroom Assignment Week Two
Date __________________________ Examiner ______________________
1. Biographic Data Name _______________________________________________ Phone________________________ Address____________________________________________________________________________ Birthdate ________________________________ Birthplace _________________________________ Age __________ Gender __________ Marital Status ______________ Occupation _______________ Race/ethnic origin __________________________________ Employer ________________________
2. Source and Reliability
3. Reason for Seeking Care
4. Present Health or History of Present Illness
Past Health
Describe general health ______________________________________________________________ Childhood illnesses __________________________________________________________________ Accidents or injuries (include age) ______________________________________________________ Serious or chronic illnesses (include age) ________________________________________________ Hospitalizations (what for? location?) ____________________________________________________ Operations (name procedure, age) ______________________________________________________Obstetric history: Gravida ____________ Term ____________ Preterm ____________ (# Pregnancies)(# Term pregnancies) (# Preterm pregnancies)Ab/incomplete _____________________ Children living _____________________ (# Abortions or miscarriages) _____
Course of pregnancy__________________________________________________________________ (Date delivery, length of pregnancy, length of labor, baby’s weight and sex, vaginal delivery or cesarean section, complications, baby’s condition)Immunizations_____________________________________________________________________ Health History Form On A Family Member/Friend
Last examination date: Physical ________________
Dental ________________ Vision ________________ Allergies _________________________________ Reaction __________________________________
Current medications _________________________________________________________________ _
6. Family History—Specify Which Relative(s)
Heart disease___________________________ High blood pressure______________________ Stroke_________________________________ Diabetes_______________________________
Blood disorders_________________________ Breast or ovarian cancer___________________
Cancer (other)__________________________ Sickle cell______________________________ Arthritis_______________________________Allergies_______________________________ Asthma _______________________________ Obesity________________________________ Alcoholism or drug addiction ______________
Mental illness ___________________________ Suicide ________________________________
Seizure disorder ________________________ Kidney disease __________________________ Tuberculosis _____
Review of Systems (Circle/highlight both past health problems that have been resolved and current problems, including date of onset.)
General Overall Health State: Present weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats or night sweats
Skin: History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion
Hair: Recent loss, change in texture
Nails: Change in shape, color, or brittleness
Health Promotion: Amount of sun exposure, method of self-care for skin and hair
Head: Any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigo
Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts
Health Promotion Eyes: Wears glasses or contacts, last vision check or glaucoma test, how coping with loss of vision, if any
Ears: Earaches, infections, discharge and its characteristics, tinnitus, or vertigo
Health Promotion Ears: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning ears. Health History Form On A Family Member/Friend
Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell
Mouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste
Health Promotion/Mouth & Throat: Pattern of daily dental care, use of prostheses (dentures, bridge), and last dental checkup
Neck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter
Breast: Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts Axilla: Tenderness, lump or swelling, rash
Health Promotion Breast: Performs breast self-examination, including frequency and method used, last mammogram and results
Respiratory System: History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure Health Promotion Respiratory: Last chest x-ray examination
Cardiovascular System: Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion it takes to produce dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia
Health Promotion Cardiovascular: Date of last ECG or other heart tests and results
Peripheral Vascular System: Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers Health Promotion Peripheral Vascular: If work involves long-term sitting or standing, avoid crossing legs at the knees; wear support hose.
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Gastrointestinal System: Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula) Health History Form On A Family Member/Friend
Health Promotion Gastrointestinal: Use of antacids or laxatives
Urinary System: Frequency, urgency, nocturia (the number of times awakens at night to urinate, recent change), 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, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or low back
Health Promotion Urinary: Measures to avoid or treat urinary tract infections, use of Kegel exercises
Male Genital System: Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia
Health Promotion Male Genital: Perform testicular self-examination? How frequently?
Female Genital System: Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding.
Health Promotion Female Genital: Last gynecologic checkup, last Pap test and results
Sexual Health: Presently in a relationship involving intercourse? Are aspects of sex satisfactory to you and partner, any dyspareunia (for female), any changes in erection or ejaculation (for male), use of contraceptive, is contraceptive method satisfactory? Use of condoms, how frequently? Aware of any contact with partner who has sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, syphilis)?
Musculoskeletal System: History of arthritis or gout. In the joints: pain, stiff-ness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gait prob-lems or problems with coordinated activities. In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease.
Health Promotion Musculoskeletal: How much walking per day? What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? Any mobility aids used?
Neurologic System: History of seizure disorder, stroke, fainting, blackouts. In motor function: weakness, tic or tremor, paralysis, coordination problems. In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent or distant, disorientation). In mental status: any nervousness, mood change, depression, or any history of mental health dysfunction or hallucinations.
Hematologic System: Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.Endocrine System: History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat or cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy. Health History Form On A Family Member/Friend
Functional Assessment (Including Activities of Daily Living)
Self-Esteem, Self-Concept: Education (last grade completed, other significant training) ______________
Financial status (income adequate for lifestyle and/or health concerns) __________
Value-belief system (religious practices and perception of personal strengths) ___________
Self-care behaviors ______________________
Activity and Exercise: Daily profile, usual pattern of a typical day ________________________________
Independent or needs assistance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, climbing stairs _________________________________
Leisure activities ________________________________________
Exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring
Sleep and Rest: Sleep patterns, daytime naps, any sleep aids used ___________________
Nutrition and Elimination: Record 24-hour diet recall. _______________________________________ _____________________________________________________________________________________
Is this menu pattern typical of most days? ___________________________________________________
Who buys food? ____________________________
Who prepares food? __________________________
Finances adequate for food? __________________________________
Who is present at mealtimes? __________________________________
Interpersonal Relationships and Resources: Describe own role in family _________________________
How getting along with family, friends, co-workers, classmates ______________________
Get support with a problem from? ______________________________________________
How much daily time spent alone? _______________________________________________________ Is this pleasurable or isolating? ___________________________________________________________
Coping and Stress Management: Describe stresses in life now __________________________________ _____________________________________________________________________________________ Change(s) in past year ______________________________________________
Methods used to relieve stress _______________________
Are these methods helpful? ___________________________
Personal Habits:
Daily intake caffeine (coffee, tea, colas) ______________________________________
Smoke cigarettes? ____________________________ Number packs per day ______________
Daily use for how many years __________________ Age started ___________
Ever tried to quit? ____________________________ How did it go? _____________________________
Drink alcohol? ____________________ Date of last alcohol use _______
Amount of alcohol that episode __________________________________________________________
Out of last 30 days, on how many days had alcohol? ____________________________________
Ever told had a drinking problem? ________________________________________________________ Any use of street drugs? ___________Marijuana? _________________________________
Cocaine? __________________________________ Crack cocaine? ______________________________ Amphetamines? _____________________________ Heroin? __________________
Prescription painkillers? _____________________ Barbiturates? _______________________________ LSD? _____________________________________
Ever been in treatment for drugs or alcohol? ________________________________________________
Environment and Hazards: Housing and neighborhood (type of structure, live alone, know neighbors) _____________________________________________________________________________________
Safety of area _________________________________________________________________________ Adequate heat and utilities ____________________________________________________________
Access to transportation ____________________________________________________________
Involvement in community services _______________________________________________________ Hazards at workplace or home ___________________________________________________________ Use of seatbelts ____________________________________________________________________
Travel to or residence in other countries ___________________________________________________ Military service in other countries ________________________________________________________ Self-care behaviors _____________________________________________________________________ Intimate Partner Violence: How are things at home? Do you feel safe? __________________
Ever been emotionally or physically abused by your partner or someone important to you___-
Ever been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner? _____________________________________________________________________________________ Partner ever force you into having sex? ____________________________________________________ Are you afraid of your partner or ex-partner? ________________________________
Occupational Health:
Please describe your job. ______________________________________________
Work with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)? ___________________________________________________________________________________
Any equipment at work designed to reduce your exposure?
Any work programs designed to monitor your exposure? _________________________________
Any health problems that you think are related to your job? _____________________________
What do you like or dislike about your job? _________________________________________________
Perception of Own Health:
How do you define health? ________________________________________
View of own health now ________________________________________________________________
What are your concerns? ________________________________________________________________
What do you expect will happen to your health in future? _______________________
Your health goals ______________________________________________________________________
Your expectations of nurses, physicians ___________________________________________________ Health History Form On A Family Member/Friend
