COMPLETE HEALTH HISTORY FORMAT

BIOGRAPHICAL DATA

Name : Marital Status: Age:

Address: Religious or Spiritual Practices:
Phone: Educational level
Gender: Occupation:
Provider of history (patient/other): Significant others or Support persons:
Birth date: Race:
Place of birth: Primary & Secondary languages (spoken/read):
Advance directive explained yes no Living will on chart? yes no

Reasons for Seeking Health Care

Major health problem or concern
Fears and past experiences)
History of Present Health Concern (Using COLDSPA in narrative form)
C- how does it fell, look, smell, sound, etc.?
O- When did it begin: is it better, worse, or the same since it began?
L-Where is it? Does it radiate?
D-how long does it last? Does it recur?
S- How bad is it on a scale of 1 (barely noticeable) to 10 (Worst pain ever experienced?)
P-What makes it better? What, makes it worse?
A-What other symptoms do you have with it? Will you be able to continue doing your work or other activities
(leisure or exercise?)

Past Health History

Problems at birth
Childhood illnesses
Immunizations to date
Adult illnesses (physical, emotional, mental)
Surgeries
Accidents
Prolonged pain or pain patterns
Allergies
Physical, emotional, social, or spiritual weaknesses
Physical, emotional, social, or spiritual strengths

Family Health History

Genogram
Age of parents (living? Date of death?)
Parents’ illnesses and longevity
Grandparents’ illnesses and longevity
Aunts’ and uncles’ ages and illnesses and longevity
Children’s ages and illnesses or handicaps and longevity

Physical Examination (See Appendix B Physical Assessment Guide Pp. 889-893)

Vital signs:
Height: Weight: BMI:

Mental Status and Substance Abuse

Observe LOC, posture and body movements, facial expressions, speech, mood, feelings, and expressions, though
process and perceptions
assess cognitive abilities
give client a specimen cup if sample is needed, and ask client to empty bladder and change into gown
ask client to sit on examination table

Head and Neck

General Appearance:
Skin:
Hair and Nails:
 Head:
Eyes:
Ears:
Nose:
Throat and Mouth:
Neck:
Musculoskeletal-Upper Extremeties
Thorax
Lungs
Breast
Lymph Nodes:
Breast Malignancy:
Heart
Abdomen
Musculoskeletal-Lower Extremeties
Spine
Genitalia (Female/Male)
Anus and Rectum

Review of Structures and Systems

Head – Do you get headaches? If, so, where are they and how painful are they? How often do they occur, and
how long do they last? Does anything trigger them, and how do you relieve them? Have you ever had a head injury? Do
you have lumps or bumps on your head?
Eyes- When was your last eye examination? Do you wear glasses? Do you have glaucoma, cataracts, or color
blindness? Does light bother your eyes? Do you have excessive tearing; blurred vision; double vision; or dry, itchy,
burning, inflamed, or swollen eyes?
Ears- Do you have loss of balance, ringing in your ears, deafness, or poor hearing? Have you ever had ear
surgery? If so, why and when? Do you wear a hearing aid? Are you having pain, swelling, or discharge from your ears? If
so, has this problem occurred before, and how frequently?
Nose- Have you ever had nasal surgery? If so, why and when? Have you ever had sinusitis or nosebleed? Do
you have nasal problems that impair your ability to smell or that cause breathing difficulties, frequent sneezing, or
discharge
Mouth and Throat- Do you have mouth sores, dry mouth, loss of taste, toothache, or bleeding gums? Do you
wear dentures and, if so, do they fit? Do you have a sore throat, fever, or chills? How often do you seen a doctor for
this?
Do you have difficulty swallowing? If so, is the problem with solids or liquids? Is it a constant problem or does it
accompany a sore throat or another problem? What, if anything, makes it go away?
Neck- Do you have swelling, soreness, lack of movement, stiffness, or pain in your neck? If so, did something
specific cause it to happen? How long have you had this symptoms? Does anything relieve it aggravate it?
Respiratory system- Do you have shortness of breath on exertion or while lying in bed? How many pillows do you
use at night? Does breathing cause pain or wheezing? Do you have productive cough? If so, do you cough up blood? Do
you have night sweats?
Have you ever been treated for pneumonia, asthma, emphysema, or frequent respiratory tract infections? Have you
ever had a chest X-ray or tuberculin skin test? If so, when and what were the results?
Cardiovascular system – Do you have chest pain, palpitations, irregular heartbeat, fast heartbeat, shortness of
breath, or a persistent cough? Have you ever had an electrocardiogram? If so, when?
Do you have high blood pressure, peripheral vascular disease, swelling of the ankles and hands, varicose veins, cold
extremities, or intermittent pain in your legs?
Breast and axilla – ask women: Do you perform monthly breast self-examinations? Have you noticed a lump, a
change in breast contour, breast pain, or discharge from you nipples? Have you ever had breast cancer? If not, has
anyone else in your family had it? Have you ever had mammogram? When and what were the results?
Ask men : Do you have pain in your breast? Have you noticed lumps of change in contour?
Gastrointestinal system – Have you had nausea, vomiting loss of appetite, heartburn, abdominal pain, frequent
belching, or passing of gas? Have you lost or gained weight recently? How often do you have a bowel movement, and
what color, and consistency are your stools? Have you noticed change in your regular elimination pattern? Do you use
laxatives frequently ? have you had hemorrhoids, rectal bleeding, hernias, gallbladder disease, or liver disease?
Genitourinary system – Do you have urinary problems, such as burning during urination, incontinence, urgency,
retention, reduced urinary flow, and dribbling? Do you get up during the night to urinate? If so, how many times? What
color is your urine? Have you ever noticed blood in it? Have you ever been treated for kidney stones?
Reproductive system – ask the women these questions: How old were you when you started menstruating?
How often do you get your period, and how long does it usually last? Do you have pain or pass clots? If you’re past
menopause, at what age did you stop menstruating? If you’re in the transitional stage, what symptoms are you
experiencing? Have you ever been pregnant? If so, how many times? How many pregnancies resulted in live births?
What was the method of birth? How many resulted in miscarriages? Have you had an abortion?
What’s your method of birth control? Are you involved in a long term monogamous relationship? Have you had frequent
vaginal infections or a sexually transmitted disease (STD)? When was your last gynecologic examination and
papanicolaou test? What were results ?
Ask men thee questions: Do you perform monthly testicular self-examination? Have you ever had a prostate
examination, and if so, when? Have you noticed penile pain, discharge, or lesions or testicular lumps? Which form of
birth control do you use? Have you had a vasectomy? Are you involved in a long-term, monogamous relationship? Have
you ever had an STD?
Musculosketal system– Do you have difficulty walking, sitting or standing? Are you steady on your feet or do
you lose your balance easily? Do you have arthritis, gout, a back injury, muscle weakness, or paralysis?
Neurologic system – have you ever had seizures? Do you ever experience tremors, twitching, numbness, tingling or loss
of sensation in a part of your body? Are you less able to get around than you think you should be?
Endocrine System – have you been unusually tired lately? Do you feel hungry or thirsty more often than usual?
Have you lost weight for unexplained reasons? How well can you tolerate heat or cold? Have you noticed changes in
your hair color or texture? Have you been losing your hair? Do you take hormone medications?
Hematologic System – have you ever been diagnosed with anemia or blood abnormalities? Have you ever had a
blood transfusion? If so, did you have an adverse reaction?
Psychological status – do you ever experience mood swings or memory loss? Do you ever feel anxious,
depressed, or unable to concentrate? Are you feeling unusually stressed? Do you ever feel unable to cope?

Lifestyle health practices or 11 Gordon’s Functional Health Patterns

Developmental Level

Laboratory Test/Diagnostics Test

PATHOPHYSIOLOGY
NCP
DRUGS
HEALTH EDUCATION PLAN
MEDICAL MANAGEMENT
RESEARCHES/RECOMMENDATION