The Complete Health History Theses

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)

Chief Complaint (CC)

1. Location 2. Character or Quality 3. Quantity or Severity 4. Timing 5. Setting 6. Aggravating or Relieving Factors 7. Associated Factors 8. Patient's Perception

1. Onset (Exactly when did it first occur?) 2. Duration (How long did it last?) 3. Frequency (How often does it occur?)

prior to arrival

Health History

Pathological conditions resulting from a previous disease (e.g., rheumatic fever, scarlet fever, poliomyelitis).

1. Childhood Illnesses 2. Accidents or Injuries 3. Serious or Chronic Illnesses 4. Hospitalizations 5. Operations 6. Obstetric History 7. Immunizations 8. Last Examination Date 9. Allergies 10. Current Medications

1. Cause 2. Name of hospital 3. How the condition was treated 4. Duration 5. Name of physician

1. Type of surgery 2. Date 3. Name of surgeon 4. Name of hospital 5. How the person recovered

1. Gravidity (pregnancies): Grav # 2. Full term deliveries (term): Term # 3. Preterm pregnancies (preterm): Preterm # 4. Incomplete pregnancies (abortions): Ab # Spontaneous (S) #; Induced (I) # 5. Children living (living): Living #

A graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations, such as parents, grandparents, siblings.

dizziness

sharpness; clarity; severity (as of pain)

double vision

difficulty swallowing

shortness of breath

excessive urination at night

limping, frequently due to insufficient blood flow to the leg muscles

inflammation of a vein resulting in a thrombus

blood clot in a vein that remains where it formed

esophageal and stomach burning sensation with sour eructation

an abnormal duct or passageway leading from an organ to the body surface, or to another organ, usually resulting from an injury or disease

pain during sexual intercourse

constant excessive thirst

excessive appetite or eating

1. bathing 2. dressing 3. toileting 4. eating 5. walking

Instrumental activities of daily living (those needed for independent living)

1. housekeeping 2. shopping 3. cooking 4. doing laundry 5. using the telephone 6. managing finances 7. nutrition 8. social relationships and resources 9. self-concept and coping 10. home environment

faith, influence, community, address

To incorporate a person's spiritual values into the health history.

1. Cut down 2. Annoyed 3. Guilty 4. Eye opener

a fluid-filled cavity or duct, especially in the scrotum

HEEADSSS

Home environment Education & Employment Eating peer-related Activities Drugs Sexuality Suicide/depression Safety