NURSING HEALTH HISTORY PAST HEALTH HISTORY

Problems at birth
ASSESSMENT Findings:

Childhood illnesses
BIOGRAPHICAL DATA
Findings:
Name:
Address:
Immunization to date
Phone:
Findings:
Gender:
Provider of History (patient/other):
Adult illnesses (physical,emotional,mental)
Birth Date:
Findings:
Birth Place:
Ethnic Background:
Surgeries:
Primary & Secondary Language (spoken&read):
Marital Status:
Accidents:
Religious or Spiritual Practices:
Educational Level:
Prolonged Pain or Pain Pattern:
Occupation:
Findings:
Significant Others/Support Person (availability):
Allergies:
REASON FOR SEEKING HEALTH CARE Physical, emotional, social, or spiritual
Reason for seeking health care (major health weaknesses
problem or concern) Findings:
Findings:
Physical, emotional. social, or spiritual strengths
Feelings about seeking health care (fears and past Findings:
experiences)
Findings:

HISTORY OF PRESENT HEALTH CARE CONCERN FAMILY HEALTH HISTORY

(COLDSPA) Age of parents (living? date of death?)
Character (how does it feel,look,smell, sound etc.?) Findings:
Findings:
Parents illnesses and longevity
Onset (when did it begin,is it better, worse, or the same Findings:
since it began?)
Findings: Grandparents illnesses and longevity
Findings:
Location (where is it? Does it radiate?)
Findings: Aunts and Uncles illnesses and longevity
Findings:
Duration (how long does it last? Does it recur?)
Findings: Children’s Ages and illnesses or handicap and
longevity
Severity (how bad is it on a scale of 1 to 10?) Findings:
Findings:

Pattern (what does make it better or worse?)

Findings:

Associated Factors (what other symptoms do you

have with it? Will you be able to continue doing your
work or other activities?)
Findings:
REVIEW OF SYSTEM (WITH / NO) Findings:

Anus, rectum & prostate: pain, with defecation,

Skin, hair, & nails: color, temperature, condition, hemorrhoids, bowel habits, constipation, diarrhea, blood
rashes, lesions, excessive sweating, hair loss, dandruff in stool.
Findings: Findings:

Head & neck: headache, stiffness, difficulty swallowing,
enlarged lymph nodes, sore throat
Findings:
Ears: pain, ringing, buzzing, drainage, difficulty hearing,
exposure to loud noises, dizziness, drainage
Findings:
Eyes: pain, infections, impaired vision, redness, tearing,
halos, blurring, black spot, double vision
Findings:
Musculoskeletal: pain, swelling, redness, stiff joints,
strength of extremities, abilities to care for self and work
Neurologic: mood, behavior, depression, anger,
headaches, concussions, loss of strength of sensation,
coordination, difficulty with speech, memory problems,
strange thoughts of action, difficulty reading or learning
Findings:

Mouth, throat, nose & sinuses: mouth pain, sinuses,

sore throat, lesions, hoarseness, nasal obstruction,
sneezing, coughing, snoring, nosebleeds
Findings:

Thorax & Lungs: pain, difficulty breathing, shortness

of breath with activities, orthopnea, cough, sputum,
hemoptysis, respiratory infection
Findings:

Breast and regional lymphatics: pain, lumps,

discharge from nipples, dimpling or changes in breast
size, swollen and tender lymph nodes axilla
Findings:

Heart and Neck Vessel: chest pain or pressure,

palpitations, edema, last blood pressure, last ECG
Findings:

Peripheral Vascular: leg or feet pain, swelling of feet

or legs, sores on feet or legs, color of feet or legs
Findings:

Abdomen: pain, indigestion, difficulty swallowing,

nausea, vomiting, gas, jaundice, hernias
Findings:

Male Genitalia: painful urination, frequency or

difficulty starting or maintaining urinary system, blood in
urine, sexual problems, penile lesions, penile pain,
scrotal swelling, difficulty with erection/ejaculation,
exposure to STI’s
Findings:

Female Genitalia: pelvic pain, voiding pain, sexual

pain, voiding problems (dribbling, incontinence) age of
menopause (date of last menstrual period) pregnancies
and types of problems, abortion, STI, HRT, birth control
methods