Professional Documents
Culture Documents
Comprehensive Adult Health History
Comprehensive Adult Health History
Date:______________________
Time: ______________________
IDENTIFYING DATA
Name:
Age:
Gender:
Address:
Marital status
Occupation
Quality
Quantity or severity
Timing
o Onset
o duration
o frequency
o time (am/pm)
Aggravating factors
Relieving factors
Associated manifestations or
symptoms
Medication taken
o Name / Dose /Route /Frequency
of use / Reaction to med
Allergies (if related to present illness)
Childhood Illnesses
Measles Rubella Mumps whooping chickenpox
cough
Medical
Diabetes Hypertension Hepatitis Asthma human
immunodeficiency
virus (HIV)
Surgical:
Dates indications types of operations
Obstetric/Gynecologic:
Obstetric history Gravida Term Alive complications
Para Preterm Aborted
Living
Psychiatric:
Illness time frame diagnosis hospitalizations
treatments medications
Health Maintenance:
immunizations
tetanus varicella tuberculin tests results of labs
pertussis hepatitis B Pap smears when they were
diphtheria HPV mammograms last performed
polio meningococcal stool tests for
measles disease occult blood
rubella Haemophilus colonoscopy
mumps influenzae type B cholesterol tests
influenza Pneumococci
herpes zoster
age and health
age and cause of death
FAMILY HISTORY symptoms reported by the patient.
breast, ovarian, colon, or prostate cancer, genetically transmitted diseases
Grandparents
sources of support
Educational level
General
recent weight change weakness fatigue fever
Skin:
Rashes lumps sores itching dryness
Head
Headache head injury dizziness lightheadedness
Eyes:
Vision glasses or contact last examination
lenses
pain redness excessive tearing double or blurred spots
vision
specks flashing lights glaucoma cataracts
Ears
Hearing tinnitus vertigo earaches infection
Neck:
Swollen glands enlarged thyroid/goiter lumps pain stiffness in the neck
Breasts:
Lumps pain or discomfort nipple discharge self-examination breastfeeding
practices.
Respiratory:
Cough productive sputum (color, hemoptysis shortness of breath wheezing
non-productive quantity) (dyspnea)
pain with a deep asthma bronchitis emphysema pneumonia
breath (pleuritic pain)
tuberculosis last chest x-ray
Cardiovascular:
high blood pressure rheumatic fever heart murmurs chest pain or palpitations
discomfort
shortness of breath need to use pillows at paroxysmal nocturnal edema
night to ease breathing dyspnea
(orthopnea)
results of past other cardiovascular
electrocardiograms tests
Gastrointestinal:
Trouble swallowing heartburn appetite nausea vomiting
Bowel movements stool color and size change in bowel pain with defecation rectal bleeding
habits
black or tarry stools hemorrhoids constipation diarrhea Abdominal pain
food intolerance excessive belching or Jaundice liver gallbladder problems
passing of gas
hepatitis
Peripheral vascular
Intermittent leg pain leg cramps varicose veins past clots in the veins swelling in calves,
with exertion legs, or feet
(claudication)
color change in swelling with redness
fingertips or toes or tenderness.
during cold weather
Urinary:
Frequency of polyuria nocturia urgency burning or pain
urination during urination
blood in the urine urinary infections kidney or flank pain kidney stones ureteral colic
(hematuria)
suprapubic pain incontinence reduced caliber or dribbling (male)
force of the urinary
stream, hesitancy (male)
Genital:
Male:
Hernias discharge from or testicular pain testicular masses scrotal pain or
sores on the penis swelling
history of sexually treatments. Sexual habits, birth control Concerns about HIV
transmitted infections interest, function, methods, condom use, infection.
satisfaction and problems.
Female:
Age at menarche regularity menst. frequency duration of periods amount of bleeding
irregular
Musculoskeletal:
Muscle or joint pain stiffness arthritis gout backache
If present, describe swelling redness pain tenderness
location of affected
joints or muscles
weakness limitation of motion
or activity
timing of symptoms duration any history of trauma
(e.g., morning or
evening)
neck pain low back pain Joint pain with
systemic symptoms
(fever, chills, rash, anorexia,
weight loss, or weakness)
Psychiatric:
Nervousness tension mood depression memory change
Neurologic:
Changes in mood or changes in speech changes in headache
attention orientation/ memory/
judgment
dizziness vertigo fainting blackouts weakness
paralysis numbness or loss of tingling or “pins and tremors involuntary
sensation needles,” movements
seizures
Hematologic
Anemia easy bruising or past transfusions transfusion reactions
bleeding
Endocrine:
thyroid problem heat or cold excessive sweating excessive thirst or polyuria
intolerance hunger
change in glove or
shoe size