Health history for SP

October 7, 2020

Hello, my name is Soni Bhuju, I am L2 the nursing student that has been assigned to you. Before we get
started, can I just get your full name and your date of birth please?

Thank you

I just want to let you know that everything that you say will only ever stay between us and the healthcare team
who will take care of you. But the only time I have to break confidentiality is when you are a danger to yourself
and others.

Alright lets get started, What brings you in today, Ms. SP?

Cultural background, Occupation Are you taking any medications?

We will take good care of u and howevere if anyhing happens go to emergecy

I will just ask a couple of question to get a general idea of what is going on.

DO you have any allergies? Do you have any history of mental disorder, cardiovascular, neurological diseases or
any other illness that you believe we should know Do you have any history of these diseases in your family
member? Do you smoke, drink or use any kind of recreational drug? Were you ever hospitalized? Have you had
any surgery? Have you been noticing changes or problems in your eating and sleeping habits? Have even been
involved in a serious accident? How would you say your lifestyle is like? Sedetary, active? Have you received all
your immunizations? We will also ask about obstetrical history? Any term birth pre term birth? Did you have any
abortions? Do you have any children? How do you perceive your health and well being and how health is
managed? How do you think your food and fluid consumption relative to your need? How rested or sleep patterns
have been like? How well do you cope with the stress and what do you do when you get stressed out? F

I will ask you some more questions just to see how you are thinking. Is that alright?

What's todays date? And month? Can I get your full complete name? And Date of birth? Do you know where you
are at today? Good. If you had to call taxi to get home from here, can you give general direction to get back home?
Can you try and complete this statement ?
- cat is to kitten and dog is to - What is the difference between
 - A pen and a pencil? - Can you write your name in the paper for me? - I will tell you four objects
and I want you to
remember them for 5 mins. You can repeat after me. Red rose, empty case, heavy bag and northrum street. Why do
not you try saying them one more time. Now what would you call this ? Show an object 'If a tiger was killed by the
lion, which animal
would be dead? How many nickels are there in a dollar ? Can you spell WORLD backwards? What were the four
things i asked you to remember? Can you write down your name on the paper for me? What would you do if you
find a phone on the street Can you tell me your mother's maiden name? How is your mood today ? On a scale to 1
to 10 1 being meh and 10 being very happy what would you rate your mood? Have you noticed any changes in
your behaviour lately, any changes in your mood? how do u handle moodiness or other negative emotions? Have
you had any thoughts of harming yourself and others? - Thank you for answering these questions

- Looks they look stated age

Their gender, race - Distinguishing marking - Hygiene - Dress appropriately
B- behaviour
- Is the person settled - fidgeting - Nervous
impulsive - Restless - Eye contact - Attitude of their towards me\
S- speech
- Rhythm - Articulation - Spontaneous
C- cognition
- Observing orientation towards time,
place and person Their reading and writing skills Memory retention skills Abstract thinking
Judgment and insight
o Healthy choices pertaining towards life and illness
o Medication regime, positive lifestyle changes?
o What brought you to hospital
A- Affect and mood
- How the patient presents to you as a
interviewer (youth thymic, bright sad, irritable, angry, depressed)
Blunted - subdued intensity - Flat affect - low display of emotion - Mood - how they are feeling
On a scale of zero to ten of being blah and 10 being horray how do you feel today? 'o State mood
matches their affect ( do they display how they feel)
T- Thought content and perception
- Suicidal homicidal and self harm ideation
o If they have any thoughts of harming themselves or others
• Yes then suicide risk assessment, assess for phobias, compulsions, obesses,, delusion or
gradeu ideas, hallucinations

T - Though Process
 - Assess directness of responses - Flow of speech - Use of vocab
Goal-orientated Tangential - flight of ideas

Begin by assessing physical appearance and behaviour during the health history
Appropriately dressed - Good hygiene - Erect posture - Direct eye contact - Facial
and movement should correspond

Cognitive ability

Now I need to ask you a few more questions. Will that be alright?
- What's today's date?
Your full complete name? And Date of birth? Do you know where you are at today? Good. If you had to
call a taxi to get home from here, can you give a general direction to get back home? Try and complete this
statement :
o Cat is to kitten and dog is to Difference between:
- Subtract 7 from 50 until you reach 8
Test their ability to write their name or draw a clock face Begin with immediate recall
o Should be able to recall or repeat 7 to 8 number forwards or 4 to 6 numbers back wards
Look at these five items and ask them to recall the object after ten mins
'o Can you look at the five items and I will ask you to recall them for me in ten mins - Remote memory -
by asking about verifiable past information
o Can you tell me your mother's madien name?
o Which school did you go to? - Judgment
'o What would you do if you find a phone in the street ?
• Patient should provide reasonable responses
Emotional stability
'o How is your mood today?
o Have you noticed and how do you handle moodiness or other negative emotions
As you talk, note thought pattern and content - should be easy to follow and logical - goal directed and
behaviour should reflect emotional content of the conversation Speech and language skills - clear
strong - fluid and articulate - express her thoughts clearly
name 10 cities, 10 countries, 10 colors and 10 vegetables.
Can you spell world backwards?
Can you make a copy of this cube?
Wha In the examination, explain it to them
- Orientation
Short term memory Naming object Following commands Word finding
 Concentration - Mathematical problems - Judgment
| Spatial orientation and construction
Abstract reasoning Comprehension of written and speaking or speeh

Introduction Confidentiality Two identifier Reason for seeking care I will ask you some questions just to see how
you are thinking some will be easy, some will be hard. Do not get upset. Is that okay? I will give u an example.
How old are you? Do you know where you are at today? Good. If you had to call taxi to get home from here, can
you give general direction to get back home?
Today is what date? I will tell you three objects and I want you to remember them for 5 mins. You can
repeat after me. Red rose, Black dog, heavy bag. Why do not you try saying them one more time. Now what
would you call this?
If a tiger was killed by the lion, which animal would be dead? Can you say no, and if or buts Can you
read this? Can you write it is a cold and cloudy day How many nickels are there in a dollar ? Can you show me
your right pinky finger? This one is a little hard but Can you t were the three things i asked you to remember
Thank you for answering all my question