Nursing Health History Form (Adult)

DEMOGRAPHIC DATA Types of Operation: ________________________________________________________

Name: Date of Admission: Obstetric/ Gynecologic
Address:
Obstetric history: Gravida ____ Para ____
Birthdate: Age: Civil Status: Sex: Menstrual history: ___________________
Methods of contraception: ____________

Psychiatric
Religion: Citizenship Educational Attainment:
Illness and time frame: ______________________
Diagnoses: _______________________________
Hospitalizations: __________________________
Occupation: Health Care Financing:
Treatment: _______________________________
Medical Diagnosis:
Immunization History

Yes No
PART A
Tetanus
Reason for Current Admission:
Pneumonia
Influenza
MMR
History of Present Illness: Polio
Hepatitis B
Hib

Allergies

Symptoms/ Reaction Action Taken

Medicine

Food

Others

History of Family Illness

Name Age Relation to Health Status Cause of Death
Patient

Illness in the family similar to the patient’s:

Familial incidence of:

 Rheumatic Fever  Hypertension  Tuberculosis  Diabetes  Mental Illness

Others: ___________________________________________________________________

PART B: Functional Health Pattern

1. Health perception- Health Management Pattern
A. How would you describe your usual  Good
health status  Fair
 Poor
B. Are you satisfied with your usual  Yes
health status?  No. Sources of dissatisfaction?
_______________________________________
Past Medical History
CHILDHOOD ILLNESSES: C. Tobacco use? Current
 Yes. # of packs/day? __ Date started: _______
 Measles  Rubella  Chicken Pox  Mumps Whooping cough Rheumatic  No
fever  Scarlet Fever  Polio  Hepa A  Hepa B  Diarrhea  Pneumonia
Others: ______________________________________ Past
ADULT ILLNESSES:  Yes. # of packs/day? __ Date started: _______
Date quit: _________
Medical Illnesses  No
D. Alcohol use?  Yes. How much and what kind? ___________
 Diabetes  Hypertension Hepatitis Asthma HIV  No
 Hospitalizations: ________________________________________ E. Street drug use?  Yes. What and how much? ______________
 No
Surgical F. Any history of chronic diseases?  Yes. Describe: ________________
 No
Dates: _________________________ G. Have you sought any healthcare  Yes. Why? __________________
Indications: ____________________ assistance in the past year?  No
Types of Operation: ________________________________________________________
H. Are you currently working?  Yes. How would you rate your working
condition? Excellent __ Good __ Fair __
Dates: _________________________
Poor__ Describe any problem areas:
Indications: ____________________
__________________________
Types of Operation: ________________________________________________________
 No

I. How would you rate living conditions  Excellent

Dates: ________________________
at home?  Good
Indications: ___________________
 Fair
 Nursing Health History Form (Adult)
 Poor
J. Have you followed the routine  Yes
prescribed for you?  No. Why not? ______________________
K. Did you think this prescribed routine  Yes
was the best for you?  No. What would be better? ______________
L. Have you had any accidents/ injuries/  Yes. Describe: __________
falls in the past year?  No
M. Have you had any problems with  Yes. Describe: __________
cuts healing?  No
N. In the past, easy to find way to  Yes
follow suggestion for doctors or  No
nurses?
O. If appropriate: What do you think
caused this illness?
P. Action taken when symptoms
perceived?
Q. Results of action?
R. If appropriate: What is important to
you while you are here? How can we
be most helpful?
S. Do you do (breast/testicular) self-  Yes. How often? _______
examination?  No
2. Nutritional and Metabolic Pattern
A. Any weight gain in the last 6  Yes. Amount: ______
months?  No
B. Any weight loss in the last 6 months?  Yes. Amount: ______
 No
C. Would you describe your appetite as  Good
 Fair
 Poor. Describe: ______________
D. Do you have any food intolerances?  Yes. What? ___________
 No
E. Do you have any dietary restrictions?  Yes. What? ___________
 No
F. Describe an average day’s food intake for you (meals and snacks)
Protein Carbohydrates
Food Item Fat (grams)
(grams) (grams)
G. Describe an average day’s fluid
intake for you.
H. Describe food likes and dislikes
I. Would you like to  Gain weight
 Lose weight
 Neither
J. Any problems with Nausea
Yes. Describe: _______
 No
Vomiting
 Yes. Describe: ______
 No
Swallowing
 Yes. Describe: ______
 No
Chewing
 Yes. Describe: ______
 No
Indigestion
 Yes. Describe: ______
 No
K. Skin Problems  Yes. Describe: _____
 No
L. Dental Problems  Yes. Describe: _____
 No
3. Elimination Pattern
A. What is your usual frequency of  Diarrhea
bowel movements  Constipation
 Ostomy
 Normal
B. Character of stool: Consistency
 Hard
 Soft
 Liquid
Color
 Brown
 Black
 Yellow
 Clay colored
Bleeding with bowel movements
 No
 Yes
C. History of constipation?  Yes. When? _____
 No
D. Use of bowel movement aids  Yes. Describe: ________
(laxatives, suppositories, diet)  No
E. History of diarrhea?  Yes. When? _____
 No
F. History of incontinence?  Yes
 No
Related to increased abdominal pressure
(coughing, laughing, sneezing)
 Yes
 No
G. History of recent travel  Yes. Where?
 No
H. Usual voiding pattern a. Frequency (times/day): ________________
b. Urination
 Retention
 Frequency
 Incontinent
c. Presence of pain
 Yes. Characteristics: _________________
 No
d. Presence of burning sensation
 Yes
 No
e. Sensation of bladder spasms
 Yes
 No
I. Perspiration Excessive
 Yes
 No
Odor problems
Energy (kcal)
 Yes
 No
4. Activity-Exercise Pattern:
A. Using the following Functional Level Feeding: ______
Classification, have the patient rate each Bathing/ Hygiene: _______
area of self-care: Dressing/grooming: _______
0= completely independent Toileting: ______
1= requires use of equipment/device Shopping: ______
2= requires help from another person for Bed mobility: _______
assistance, supervision, or teaching General mobility: _____
3= requires help from another person Home maintenance: ______
and equipment or device
4= dependent, does not participate in
activity
B. Oxygen use at home?  Yes. Describe: _______
 No
C. How many pillows do you use to
sleep on?
D. Do you frequently experience  Yes. Describe: _______
fatigue?  No
E. How many stairs can you climb
without experiencing any difficulty?
F. How far can you walk without
experiencing any difficulty?
G. Any history of falls?  Yes. How often? ______
 No
H. Has assistance at home for care of  Yes. Who? ______
self and maintenance of home?  No
I. Any complaints of weakness or lack  Yes. Describe: ______
of energy?  No
J. Any difficulties in maintaining  Yes. Describe: ______
activities of daily living?  No
K. Any problems with concentration?  Yes. Describe: ______
 No
L. If in wheelchair, do you have any  Yes. Describe: ______
problems manipulating the  No
wheelchair?
M. Can you move yourself from site to  Yes. Describe: ______
site with no problems?  No
5. Sleep-Rest Pattern
A. Usual sleep habits Hours/ night: ____
Naps
 Yes. AM or PM? ____
 No
Feel rested
 Yes
 No. Describe: ________
 Nursing Health History Form (Adult)
B. Any problems Difficulty going to sleep
 Yes  Yes. Children? __ Yes. # of children: _____
 No __ No
Awakening during the night  No
 Yes
 No Name of children Age Premature/ Full-term
Early awakening
 Yes
 No
Insomnia
 Yes. Describe: _________
 No
C. Methods used to promote sleep Medication
 Yes. What? _________
C. Any family problems you have  Not applicable
 No
difficulty handling?  No difficulty with
Warm fluids
 Average
 Yes. What? _________
 Some difficulty with. Describe: ________
 No
Relaxation technique
D. Any losses (physical,  Yes. Describe: ________
 Yes
psychological, social) in the past  No
 No
year?
6. Cognitive-Perceptual pattern
E. How is the patient handling this
A. Hearing difficulty  Yes. Describe: _________
loss at this time?
 No
F. Do you believe this admission will  Yes. Describe: _________
B. Vision Wear glasses
result in any type of loss?  No
 Yes. Last checked: _______
G. Family depends on you for  Yes. How are you managing? _________
 No
things?  No
C. Memory Change in memory lately
H. If appropriate: How do
 Yes. Why? ________
family/others feel about your
 No
illness/hospitalization?
D. Pain Location (have the patient point to area): ______
I. Belong to Social groups
Intensity (have the patient rank on scale): ______
 Yes
Radiation
 No
Yes. Where? ________
Close friends
 No
 Yes
Timing: __________
 No
Duration: ________
What do you do to relieve pain at home? _______ J. Feel lonely  Yes. Describe: _________
When did the pain begin? _____________  No
K. How would you rate your comfort  Comfortable
E. Decision-making Final decision-making in social situations?  Uncomfortable
 Easy L. How would you rate your usual  Very active
 Moderately easy social activities?  Active
 Moderately difficult  Limited
 Difficult  None
Inclined to make decision M. Things generally go well for you  Yes. Describe: _________
 Yes. Describe: _________ at work?  No
 No 9. Sexuality-Reproductive pattern
F. Knowledge level Can define what current problem is? A. Females Date of LMP _____
 Yes Any pregnancies?
 No Para: ____
Can restate current therapeutic regimen? Gravida: ____
 Yes Menopause
 No  Yes. Year: ______
7.Self-perception and Self-concept Pattern  No
A. My usual view of myself is  Positive Use of birth control measures
 Neutral  Yes. Type: _____
 Somewhat negative  No
B. Changes in your body or the things  Yes. Describe: _______  N/A
you can do  No Any history of vaginal discharge, bleeding, lesion?
 Yes. Describe: _______
C. Are these problematic for you?  Yes. Describe: _______
 No
 No
Pap smear annually
D. Changes in way you feel about  Yes. Describe: _______
 Yes. Date of last Pap Smear: ________
yourself or your body (since illness  No
 No
started)
Date of last mammogram: ________
E. Find things frequently make you Angry History of STF (sexually transmitted disease)
 Yes. Describe: _______  Yes. Describe: _______
 No  No
Annoyed
B. If admission secondary to rape Is the patient describing numerous physical
 Yes. Describe: _______
symptoms?
 No
 Yes. Describe: ________
Fearful
 No
 Yes. Describe: _______
Is the patient exhibiting numerous emotional
 No
reactions?
Anxious
 Yes. Describe: ________
 Yes. Describe: _______
 No
 No
What has been your primary coping mechanism to
Depressed
handle this rape episode? ____________
 Yes. Describe: _______
Have you talked to persons from rape crisis center?
 No
 Yes. Describe: _________
F. Ever feel you lose hope?  Yes. Describe: _______  No
 No If No, does the patient want you to contact them?
G. Not able to control things in life  Yes. Describe: _______  Yes
 No  No
If Yes, was this contact of assistance?
8. Role-relationship Pattern  Yes. Describe: _______
A. Does the patient live alone?  Yes  No
 No. With whom? _______________________ C. Male Any history of prostate problems?
 Yes. Describe: ______
B.Is the patient married?  No

D. Both
10. Coping-Stress Tolerance Pattern
A. Have you experienced any
stressful or traumatic events in
the past year in addition to this
admission?
B. How would you rate your usual
handling of stress?
C. What is the primary way to deal
with stress or problems?
D. Tense a lot of time?
E. When big problems occur in your
life, how do you handle them?
F. Most of the time, is this way
successful?
11. Value-Belief Pattern
A. Satisfied with the way your life
has been developing?
B. Will this admission interfere with
your plans for the future?
C. Religion
D. Will this admission interfere with
your spiritual or religious
practices?
E. Any religious restrictions to care
(diet, blood transfusion)?
F. Would you like to have you
(pastor, rabbi, hospital chaplain)
contacted to visit you?
Have your religious beliefs helped
you deal with the problems in the
past?
Reference:
Newfield, S.A., Hinz, M.D., Scott-Tilley, D.,
Sridaromont, K.L., & Maramba, P.J. (2007).
Cox’s clinical applications of nursing diagnosis:
Adult, child, women’s, mental health, gerontic, and
home health considerations (5th ed.). Philadelphia,
PA: F. A. Davis Company.
Nursing Health History Form (Adult)
Any history of penile discharge, bleeding, lesions?
 Yes. Describe: ______
 No
Date of last prostate exam: _________________
History of STD (sexually transmitted disease)
 Yes. Describe: ________
 No
Are you experiencing any problems in sexual
functioning?
 Yes. Describe: _________
 No
Are you satisfied with your sexual relationship?
 Yes. Describe: _________
 No
Do you believe this admission will have any impact
on sexual functioning?
 Yes. Describe: _________
 No
 Yes. Describe: ________
 No
 Good
 Average
 Poor
 Yes. What helps? ________
 No
 Yes
 No
 Yes. Comments: ___________
 No
 Yes. How? _________
 No
 Yes. How? _________
 No
 Yes. Describe: _________
 No
 Yes. Who: __________
 No
 Yes. Comments: __________
 No
Nursing Health History Form (Adult)