Taking A Health History Health History: Purpose
Taking A Health History Health History: Purpose
Taking A Health History Health History: Purpose
I. Considerations in history-taking
A. Distance
7. Silence
8. Direct questions
9. Summary
2. Insecure pattern
3. Defensive pattern
3. Have patient sit next to desk rather than peer over desk (as if
over a barrier).
4. Put the chart to the side if possible. The chart itself can be a
barrier between you and the patient.
D. Interview Structure
A. Biographical data
B. Chief complaint (CC) – problem, interest, or concern that brought
patient to seek health care. Use patient’s own word in quotes.
2. Includes:
a. Onset of problem: date, gradual or sudden
b. Setting in which it developed
c. Manifestations/signs and symptoms
Onset
Location
Duration
Character (quantity, quality)
Associated manifestations (setting, symptoms)
Relieving/aggravating Factors
Treatment
and…
d. Negative information
e. Impact on patient’s life and meaning
f. Disability assessment (social, psychological, financial)
D. Personal history and patterns of living
3. Geographic exposure
4. Lifestyle
Smoking history
How long? How many cigarettes per day?
Willingness to quit?
E. Family History
F. Past Medical History: Include: date, problem, hospitalizations,
symptoms, treatment, current status – ongoing? resolved?
prescribed by physician?
self-prescribed?
BCP? Vitamins?
will not thoroughly review each system, but must include detailed
review of systems involved with present illness
Interviewer:
Date of Interview:
A. Biographical data
2. Address:
3. Phone: __________________
B. Chief complaint(s)
C. History of present illness (HPI)
1. Onset
2. Location
3. Duration
4. Characteristic
5. Associated manifestations
6. Relieving/aggravating factors
7. Tx
4. Accidents/injuries
5. Hospitalizations
6. Surgical history
8. Medications
E. Personal history
4. Recreation/Hobbies/Exercise
6. Sexuality
7. Coping/Stressor(s)
8. Diet
F. Family health history (Diagram pedigree)
G. Sociologic System
3. Environment
4. Occupational History
5. Economic status
6. Level of Education
Methods of contraception:
14. Musculoskeletal:
Please review this tool before using it. Some questions are not
appropriate for every patient. For example, asking questions about death in the
context of minor illness may frighten the patient and give the impression that the
examiner is aware of something that the patient doesn’t know.
Respect for cultural diversity is politically correct. However, it is far more
important than being a matter of political correctness. It is a matter of simple
decency. It is a matter of an overall effort to respond to human needs. Sensitize
yourself to cultural diversity by reviewing the following ways to develop your
cultural understanding and respect:
Country of birth_________________________________________________
If raised in the U.S., were most members of your community of the same
ethnic background? Yes( ) No( )
Diet
Cultural preferences:
Religious requirements:
Are boy and girl infants treated differently? Yes( ) No( ) If so, how?
Religion
Affiliation______________________________________________________
Participation: >1 time per week ( ) 1 time per week ( ) 1 time per month ( )
Note to the examiner: Ask the following question if the patient faces a
health crisis.
When some people face a crisis such as yours, they feel angry with God.
Has the ever been your experience?
Planning
During your assessment you noted practices that are helpful and some that
may adversely affect health. In developing your plan of care, consider the
following options: