COMPLETE HEALTH HISTORY

- Provides foundation for identifying

health problems and provides a focus for
the physical assessment

-should begin with an explanation to the

client of why the information is being
requested.
 8 Sections of a Complete Health History

Biographical data
Reasons for seeking health care (Chief Complaint)
History of present health concern
Past health history
Family health history
Review of systems for current health problems
Lifestyle and practices profile
Developmental level
1. BIOGRAPHICAL DATA

Includes information that identifies the client and

who provided the information.
INITIALS (not name) are used when STUDENTS
ARE COLLECTING the information and sharing it
with the instructors. Address and contact no. should
be deleted.
CLIENT- primary source of data and all others are
secondary
BIOGRAPHICAL DATA
NAME
ADDRESS
PHONE NUMBER
GENDER
PROVIDER OF HISTORY ( PATIENT OR OTHER)
BIRTH DATE
PLACE OF BIRTH
RACE OR ETHNIC BACKGROUND
PRIMARY AND SECONDARY LANGUAGE/DIALECT
MARITAS STATUS
RELIGIOUS OR SPIRITUAL PRACTICES/ RELIGION
EDUCATIONAL LEVEL
OCCUPATION
SIGNIFICANT OTHERS OR SUPPORT PERSON (AVAILABILITY
2. REASON(S) FOR SEEKING HEALTH CARE
INCLUDES 2 QUESTIONS:

1. “What is your major health problem or

concerns at this time?”
-also known as client’s chief

complaints( CC)
 “What is your major health problem or concerns at this
time?”

Assist the client to focus on his most significant concern

Other questions like, “ Why are you here?” and “How can I
help you?” can also be asked

Reminder: use holistic approach in phrasing

questions, draw out concerns that are beyond just a
physical complaint and address other associated
factors like stress or lifestyle changes
2. REASON(S) FOR SEEKING HEALTH CARE
INCLUDES 2 QUESTIONS:
2. How do you feel about having to seek
health care?
-encourages the client to discuss fears
or other feelings /past experiences about
having to see a health care provider.
3. HISTORY OF PRESENT HEALTH CONCERN

includes questions that provide detailed

descriptions of the client’s present health
problem
Encourage the client to explain:
health problem or symptom in as much detail as possible
focusing on onset, progression and duration
signs and symptoms and related problems
what the client perceives as causing the
problem/symptom
what makes the problem worse
what makes the problem better
which treatments have been tried
what effect the problem has had on daily life
what is the client’s ability to provide self-care
 TIP: USE MNEMONICS

To gather a comprehensive history of present

concern as a nurse you may use the following
mnemonic to organize data:

PQRST or COLDSPA
Character (how does it feel, look, smell, sound?)
Onset (When did it begin: is it better, worse, or same
since it began?)
Location/radiation (Where is it? Does it radiate?)
Duration (How long it lasts? Does it recur?)
Severity (use rating scale)
Pattern (What makes it better, worse?)
Associated factors (What other symptoms do you have
with it? Will you be able to continue doing your work or
other activities ?)
Precipitating factors (What brought
about the pain? What do you do to be
relieved?)
Quality/character (What the pain feels
like? Piercing? Scalding? Crushing?
Unbearable? Killing? Intense?, How
does it look like?)
Region/Radiation (Where do you feel the
pain?)
Severity (Use rating scale 0-10/ 1-10)
Time/duration ( How long it lasts?)
4. PAST HEALTH HISTORY
elicit data related to the client’s strengths and
weaknesses in his health history
Adult illneses: Physical, social, emotional or spiritual
may also include trends of unhealthy behaviors
Vices or lack of physical activity
data obtained in this section aids the nurse to
identify risk factors that stem from previous health
problems (risk factors may be to the client or
significant others)
 Past Health History includes
questions about...
birth, growth and development
childhood diseases
immunizations to date
Allergies (food, medicine, pollens others)
Use of prescription and OTC medications
previous health problems
hospitalizations and surgeries
Pregnancies/ births (if applicable)
previous accidents and injuries
pain experiences
emotional or psychological problems
5. FAMILY HEALTH HISTORY

focuses on health problems that seem to run in

families or those that are genetically based
should include as many genetic relatives as the
client can recall
include maternal and paternal grandparents, aunts
and uncles on both sides, parents, siblings and
the client’s children
FAMILY HEALTH HISTORY

drawing a genogram helps to organize and illustrate the

client’s family history
use a standard format
provide a key for the entries
female relatives: circle
male relatives: square
deceased relative: marking an X in the circle or square and listing the age
at death
cause of death noted inside a parenthesis e.g. (heart failure )
AW (Alive and well) should be placed next to the age
Straight or vertical lines to denote relationship
Horizontal doted line to indicate client’s spouse
Vertical dotted line to indicate adoption
6. LIFESTYLE AND HEALTH PRACTICES

- Describe how they are managing

their lives, their awareness of
healthy versus toxic living
patterns
- Elicits data in the client related to
his strengths and weaknesses
Questions:

1. Description of typical day – usual pattern of daily living

2. Nutrition and weight management- recall 24 hour intake
3. Activity Level and exercise
4. Sleep and rest
5. Substance abuse
6. Self concept and self care responsibilities
7. Social Activities –det. social dev.
8. Relationships-composition of family
9. Value and belief system
10.Education and work
11.Stress level and coping styles
12.Enviroment
7. DEVELOPMENTAL LEVEL

-Focuses on growth and development of

an individual throughout the lifespan

- Freuds theory of psychosexual devt

- Erik eriksons psychosocial devt
- Piaget theory of cognitive devt
- Kholberg theory of moral devt
8. REVIEW OF SYSTEMS (SYMPTOMS)
/FOR CURRENT HEALTH PROBLEM