The Health History

- Provides a comprehensive portrait of the patient’s past and present health

- Purpose: collect subjective data
A. Personal Profile
1. Biographic Data
a. Name
b. Address and phone number
c. Age and birthdate
d. Birthplace
e. Gender
f. Marital status
g. Race, ethnic origin
h. Occupation (usual and present)
2. Chief Complaint of present illness/ Reason for seeking care
- Brief spontaneous statement in the patients’ own words that describes the reason for the
visit. It states one (possible two) signs and symptoms
o Sign – objective data
o Symptom – subjective
- Not diagnostic, so avoid translating it into terms of medical diagnosis
- Eg. Chest pain for 2 hours
Need yearly examination for work
3. Past Health History
- Past health events may have residual effects on the current state of health
- Previous experience with illness may give clues on how the patient responds to illness and
to the significance of illness for him/her

 Childhood Illness
 Adult illnesses
 Immunizations
 Allergies
 Accidents
 Hospitalization
 Surgical History
 Medications used
 Foreign Travel
 Family History
 Obstetric/Gynecological History
4. Current Medications (Medication Reconciliation
- Note all prescription and OTC medications and herbal remedies
- Ask specifically for vitamins, birth control pills, aspirin and antacids
- For each medication, note the name, dose and schedule and ask, how often do you take it
each day? “what it is for?” and how long have you been taking it.
- Prescribed medications may have adverse interactions with OTCs and herbal medications
 - This also ensures evaluation of medications taken by the patient by the physician – either
continue the medication unchanged, to continue but change the dose or discontinue the
medication.
5. Personal Habits
- Tobacco, Alcohol, Street drugs
o Tobacco use
 Do you smoke cigarettes?
 At what age did you start?
 How many packs do you smoke per day?
 How many years have you smoked?
 Have you ever tried to quit?
 How did it go?
o Alcohol
 Do you drink alcohol?
 When was your last drink of alcohol
 How much did you drink that time
 Out of the last 30 days, about how many days would you say that you drink
alcohol?
 Have you ever had a drinking problem?
 Do you have a history of alcohol treatment?
 Do you have history of family member with problem drinking?
CAGE TEST (Ewing, 1984) Screening Questionnaire to identify excessive or uncontrolled
drinking.

C – cut down (have you ever thought that you should cut down your drinking?)
A – Annoyed (have you ever been annoyed by criticism of your drinking?)
G – Guilty (Have you ever felt guilty about your drinking?)
E – Eye Opener (Do you drink in the morning?)

 If the person answers “yes” to two or more CAGE questions, suspect alcohol abuse
 If the person answers ”no” to drinking alcohol, ask the reason for this decision ( eg
psychosocial, legal, health, religion)

oIllicit/street drugs (exercise great caution when asking questions about use of drugs
 Ask specifically about marijuana, cocaine, amphetamines and barbiturates
6. Personal Setting (environment/Hazard)
a. Housing and neighborhood
i. Safety of area
ii. Adequate ventilation
References:
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier and Erb’S Fundamentals of Nursing 10Th Edition
(Tenth Edit). Pearson Education Limited.
Jensen, S. (2011). Pocket Guide For Nursing Health Assessment: A Best Practice Approach. Wolters
Kluwer Health | Lippincott Williams & Wilkins.
Weber, J. R. ., & Kelley, J. H. . (2013). Health assessment in nursing: Fifth edition. Health Assessment in
Nursing: Fifth Edition. Wolters Kluwer Health | Lippincott Williams & Wilkins