Conduct a health history on a family member or friend. You can use the form located in your Health Assessment book or from Week two classroom assignment. Be sure they give you permission. Using the interviewing techniques learned in Module 2, gather the following information. Use your textbook as your guide.
Date __________________________ Examiner ______________________ 1. Biographic Data Name _______________________________________________ Phone________________________ Address____________________________________________________________________________ Birthdate ________________________________ Birthplace _________________________________ Age __________ Gender __________ Marital Status ______________ Occupation _______________ Race/ethnic origin __________________________________ Employer ________________________ 2. Source and Reliability
3. Reason for Seeking Care
4. Present Health or History of Present Illness
Describe general health ______________________________________________________________ Childhood illnesses __________________________________________________________________ Accidents or injuries (include age) ______________________________________________________ Serious or chronic illnesses (include age) ________________________________________________ Hospitalizations (what for? location?) ____________________________________________________ Operations (name procedure, age) ______________________________________________________ Obstetric history: Gravida ____________ Term ____________ Preterm ____________ (# Pregnancies) (# Term pregnancies) (# Preterm pregnancies) Ab/incomplete _____________________ Children living _____________________ (# Abortions or miscarriages) Course of pregnancy__________________________________________________________________ (Date delivery, length of pregnancy, length of labor, baby’s weight and sex, vaginal delivery or cesarean section, complications, baby’s condition) Immunizations_____________________________________________________________________
Last examination date: Physical ________________
Dental ________________ Vision ________________ Allergies _________________________________ Reaction __________________________________
Current medications _________________________________________________________________ __________________________________________________________________________________
6. Family History—Specify Which Relative(s)
Heart disease___________________________ High blood pressure______________________ Stroke_________________________________ Diabetes_______________________________ Blood disorders_________________________ Breast or ovarian cancer___________________ Cancer (other)__________________________ Sickle cell______________________________ Arthritis_______________________________ Allergies_______________________________ Asthma _______________________________ Obesity________________________________ Alcoholism or drug addiction ______________ Mental illness ___________________________ Suicide ________________________________ Seizure disorder ________________________ Kidney disease __________________________ Tuberculosis ____________________________ Review of Systems (Circle both past health problems that have been resolved and current problems, including date of onset.) General Overall Health State: Present weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats or night sweats Skin: History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion Hair: Recent loss, change in texture Nails: Change in shape, color, or brittleness Health Promotion: Amount of sun exposure, method of self-care for skin and hair Head: Any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigo Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts Health Promotion: Wears glasses or contacts, last vision check or glaucoma test, how coping with loss of vision, if any Ears: Earaches, infections, discharge and its characteristics, tinnitus, or vertigo Health Promotion: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning ears Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell Mouth and Throat: Mouth pain, frequent sore throat, bleeding gums, tooth-ache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsil-lectomy, altered taste Health Promotion: Pattern of daily dental care, use of prostheses (dentures, bridge), and last dental checkup Neck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter Breast: Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts Axilla: Tenderness, lump or swelling, rash Health Promotion: Performs breast self-examination, including frequency and method used, last mammogram and results
Respiratory System: History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breath-ing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure Health Promotion: Last chest x-ray examination Cardiovascular System: Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion it takes to produce dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia Health Promotion: Date of last ECG or other heart tests and results Peripheral Vascular System: Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mot-tling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers Health Promotion: If work involves long-term sitting or standing, avoid crossing legs at the knees; wear support hose. Gastrointestinal System: Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula) Health Promotion: Use of antacids or laxatives Urinary System: Frequency, urgency, nocturia (the number of times awakens at night to urinate, recent change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or low back Health Promotion: Measures to avoid or treat urinary tract infections, use of Kegel exercises Male Genital System: Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia Health Promotion: Perform testicular self-examination? How frequently? Female Genital System: Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmeno-pausal bleeding. Health Promotion: Last gynecologic checkup, last Pap test and results
Sexual Health: Presently in a relationship involving intercourse? Are aspects of sex satisfactory to you and partner, any dyspareunia (for female), any changes in erection or ejaculation (for male), use of contraceptive, is contraceptive method satisfactory? Use of condoms, how frequently? Aware of any contact with partner who has sexually transmitted infection (gonorrhea, herpes, chla-mydia, venereal warts, HIV/AIDS, syphilis)? Musculoskeletal System: History of arthritis or gout. In the joints: pain, stiff-ness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gait prob-lems or problems with coordinated activities. In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease. Health Promotion: How much walking per day? What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? Any mobility aids used? Neurologic System: History of seizure disorder, stroke, fainting, blackouts. In motor function: weakness, tic or tremor, paralysis, coordination problems. In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent or distant, disorientation). In mental status: any ner-vousness, mood change, depression, or any history of mental health dysfunction or hallucinations. Hematologic System: Bleeding tendency of skin or mucous membranes, exces-sive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions. Endocrine System: History of diabetes or diabetic symptoms (polyuria, poly-dipsia, polyphagia), history of thyroid disease, intolerance to heat or cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy. Functional Assessment (Including Activities of Daily Living)
Self-Esteem, Self-Concept: Education (last grade completed, other significant training) ______________ _____________________________________________________________________________________ Financial status (income adequate for lifestyle and/or health concerns) ____________________________ _____________________________________________________________________________________ Value-belief system (religious practices and perception of personal strengths) ______________________ _____________________________________________________________________________________ Self-care behaviors ______________________________________________________________________ ___
Activity and Exercise: Daily profile, usual pattern of a typical day ________________________________ _____________________________________________________________________________________ Independent or needs assistance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, climbing stairs ___________________________________________________ _____________________________________________________________________________________ Leisure activities ________________________________________________________________________
Exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring body’s response to exercise) ______________________________________________________________ _____________________________________________________________________________________ Other self-care behaviors_________________________________________________________________
Sleep and Rest: Sleep patterns, daytime naps, any sleep aids used ____________________________________ _____________________________________________________________________________________ Other self-care behavior _________________________________________________________________ Nutrition and Elimination: Record 24-hour diet recall. _______________________________________ _____________________________________________________________________________________ Is this menu pattern typical of most days? ___________________________________________________
Who buys food? ____________________________ Who prepares food? __________________________
Finances adequate for food? ______________________________________________________________
Who is present at mealtimes? _____________________________________________________________
Other self-care behaviors _________________________________________________________________
Interpersonal Relationships and Resources: Describe own role in family __________________________
How getting along with family, friends, co-workers, classmates __________________________________ _____________________________________________________________________________________ Get support with a problem from _________________________________________________________ How much daily time spent alone? ________________________________________________________ Is this pleasurable or isolating? ___________________________________________________________ Other self-care behaviors ________________________________________________________________ Coping and Stress Management: Describe stresses in life now __________________________________ _____________________________________________________________________________________ Change(s) in past year _________________________________________________________________ Methods used to relieve stress ____________________________________________________________
Are these methods helpful? ______________________________________________________________
Daily intake caffeine (coffee, tea, colas) ______________________________________ Smoke cigarettes? ____________________________ Number packs per day _______________________ Daily use for how many years __________________ Age started ________________________________ Ever tried to quit? ____________________________ How did it go? _____________________________ Drink alcohol?_______________________________ Date of last alcohol use ______________________ Amount of alcohol that episode __________________________________________________________ Out of last 30 days, on how many days had alcohol? __________________________________________ Ever told had a drinking problem? ________________________________________________________ Any use of street drugs? _________________________________________________________________ Marijuana? _________________________________ Cocaine? __________________________________ Crack cocaine? ______________________________ Amphetamines? _____________________________ Heroin? ____________________________________ Prescription painkillers? _____________________ Barbiturates? _______________________________ LSD? _____________________________________ Ever been in treatment for drugs or alcohol? ________________________________________________
Environment and Hazards: Housing and neighborhood (type of structure, live alone, know neighbors) __________________________________________________________________________________________
Safety of area _________________________________________________________________________ Adequate heat and utilities _______________________________________________________________
Access to transportation ____________________________________________________________
Involvement in community services _______________________________________________________ Hazards at workplace or home ___________________________________________________________ Use of seatbelts ________________________________________________________________________
Travel to or residence in other countries ____________________________________________________ Military service in other countries ________________________________________________________ Self-care behaviors _____________________________________________________________________ Intimate Partner Violence: How are things at home? Do you feel safe? ___________________________ _____________________________________________________________________________________ Ever been emotionally or physically abused by your partner or someone important to you? ___________ Ever been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner? _____________________________________________________________________________________ Partner ever force you into having sex? _____________________________________________________ Are you afraid of your partner or ex-partner? ________________________________
Please describe your job. ______________________________________________
Work with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)? ____________________________________________________________________________________________________
Any equipment at work designed to reduce your exposure?
Any work programs designed to monitor your exposure? ______________________________________ Any health problems that you think are related to your job? ____________________________________ What do you like or dislike about your job? _________________________________________________ Perception of Own Health: How do you define health? ________________________________________ View of own health now ________________________________________________________________ What are your concerns? ________________________________________________________________ What do you expect will happen to your health in future? ______________________________________ _____________________________________________________________________________________ Your health goals ______________________________________________________________________ Your expectations of nurses, physicians ___________________________________________________
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