Ø Is an accurate and complete account of a person’s past and current health
Ø It describes the person’s as a whole and his interaction with the environment
Ø First step in health assessment and health history
Purpose of health history
Ø The overall goal is to evaluate the status of the person’s well being
1. To collect subjective data
2. To collect a database combining the subjective and objective data
3. To establish a trusting relationship
Uses
1. To screen people for health problems and abnormal symptoms
2. To assess lifestyle to evaluate health promotion and health maintenance and it effects to their health
3. To assess health problems and their reaction to their condition
4. To make nursing judgements and aid in developing the nursing diagnosis
5. To identify realistic goals and outcomes
6. To explore the effectiveness of a person’s efforts to manage health problems through self care
7. To initiate discharge or follow-up by identifying potential needs
Components of Health History
I. General Data
- Identifies the information of the client
· Name
· Age
· Gender
· Civil status
· Present address
· Birthday, birthplace
· Occupation
· Nationality, ethnicity, race
· Religion
· Date and time of admission
· Number of times admitted in the same hospital
II. Informant
- Sources of data whether primary or secondary
- Interpreters are also included
III. Chief Complaint
- A list of one or more symptoms that caused the client to seek medical attention
- Written as phrases only and not as complete sentences but uses the client’s own words
IV. History of Present Illness
- Strengthen the chief complaint
- Description of how each symptoms developed
- The client’s symptoms should be accurately described
- Example: Cough
- C- Chest pain
- H- Hemoptysis
- E- Easy fatigability
- W- Weight loss
- F- Fever
- I- Insomia
- N- Night sweats
- D- Dyspnea
- C- Cough
- A-Anorexia
- B- Backpain
- Previous admissions and consultation
· Related to present illness
· Usually used for chronic conditios
· Details about the last episode of the present condition
· Includes an Interval History
V. Past Medical History
- Childhood illnesses
- Previous hospitalizations
- Surgical, obstetrics and psychological conditions
- Accidents, trauma, blood transfusions
- Allergies to foods and drugs
- History of diseases like HPN, DM, asthma, goiter, PTB, arthritis
- Medications
VI. Family History
- Document presence and absence of specific diseases in the family.
- Includes both hereditary and communicable
VII. Personal and Social History
- Family of origin (# of siblings and birth order)
- Educational attainment
- Occupation
- Marital history
- Current household living conditions- sources of water, waste disposal, occupants, floor area, use of comfort rooms
- Personal interest, diet, vices, sleeping pattern, exercise
Pack years = # of sticks per day X # of years smoking/20
Significant if 5-7 yrs in male and 7-10yrs in female
VIII. Obstetric and Gynecological History
- MIDAS
· Menarche
· Interval- regular or irregular
· Duration –in days
· Amount- # of soaked pads per day
· Symptoms that accompanies- if present ex: pain
- Last Menstrual Period
- Previous Menstrual Period
- Menopause
- Obstetric Score: G_P_(T,P,A,L)
o Gravida- indicates number of pregnancy
o Parity- indicates number of viable birth (>20 weeks)
o Term- 37-42 weeks
o Preterm- delivery before 37 weeks
o Abortion- termination of pregnancy before 20 weeks or less than 500g birth weight
o Living
- Sexual History
o Coitarche
o Frequency of coitus
o History of STI
o # of sexual partners and their occupation
o Unusual sexual practices
o Use of contraception (type and duration of use)
o Symptoms: dyspareunia, post coital bleeding or discharges
IX. Review of System
- General
- Skin
- Head and neck
- Eyes
- Ears
- Nose
- Mouth
- Respiratory
- Cardiac
- Gastro-Intestinal
- Genitor- Urinary
- Musculoskeletal
- Endocrine
- Haematological
- Nervous System
- Psychiatric
