Chapter 4: The Complete Health History

1. biographic data 2. reason for seeking care 3. present health or history of present illness 4. past history 5. family history 6. review of systems 7. functional assessment or activities of daily living (ADLs)

Includes name, address, phone number, age and birth date, birthplace, gender, marital status, race, ethnic origin, and occupation.

A brief, spontaneous statement in the person's own words that describes the reason for the visit. It states one (possibly two) symptoms or signs and their duration.

For the well person, it's a short statement about the general state of health. For the ill person, it's a chronologic record of the reason for seeking care, from the time the symptom started until now.

Important because they may have effects on the current health state. Includes childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations, operations, obstetric history, immunizations, last exam date, allergies, and current medications.

Highlights diseases and conditions for which a particular patient may be at increased risk for.

Purpose of this is to evaluate past and present health state of each body system, to double-check in case any significant data was omitted, and to evaluate health promotion practices.The order of the examination of body systems is roughly head-to-toe.

Measures a person's self-care ability in the areas of general physical health or absence of illness, ADLs, and in IADLs (instrumental activities of daily living).

A subjective sensation that the person feels from the disorder.

An objective abnormality that you as the examiner could detect on physical examination or in laboratory reports.

-location -character or quality -quantity or severity -timing -setting -aggravating or relieving factors -associated factors -patient's perception

P: provocative or palliative Q: quality or quantity R: region or radiation S: severity scale T: timing U: understand patient's perception

Note both the allergen (medication, food, or contact agent) and the reaction (rash, itching, runny nose, watery eyes).

For each medication, record the name, purpose, and daily schedule. Does it work? Are there any side effects?