health history notes on template

8/15/2019 Health History Notes on Template

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MILLIKIN UNIVERSITYCollege of Professional Studies: School of Nursing

NU !!: "ealth #ssess$ent

PART I: HEALTH HISTORY

I% IDENTIFYING DATA DATE &&&&&&&&&&&&&&&&&&&&&

Initials &&&&&&&&&&&&&&&&&&& Birthplace _______ &&&&&&&&&&&&&&&& Age______________________ Ethnic Origin ____________________ DOB &&&&&&&&&&&&&&&&&&&& arital Partner Stat!s &&&&&&&&&&&& Gen"er &&&&&&&&&&&&&&&&&&& Occ!pati#n 'Usual or Present(Race &&&&&&&&&&&&&&&&&&&&& Religi#n &&&&&&&&&&&&&&&&&&&&&&&& Pri$ar% Lang!age &&&&&&&&&&&&&&&&&&&& Interpreter nee"e"& Y N

II' SO(R)E OF INFOR ATION 'include source and relia)ilit*(+ ,ho is gi-ing *ou this infor$ation.+ "o/ /illing are the* to co$$unicate.+ #re the ans/ers consistent 'as0 1uestions in $ulti2le /a*s(.+ "o/ relia)le are the*.+ Note an* s2ecial circu$stances3 such as use of inter2reter%

III%REASON FOR SEE*ING )ARE+ Put in 2erson4s o/n /ords descri)ing reason for -isit% PUT IN 5U6T#TI6NS%+ 7on4t use $edical ter$inolog*+ #s0 for their signs and s*$2to$s 'itching3 2ain3 nausea3 etc%(

IV%PRESENT HEALTH #r HISTORY OF PRESENT ILLNESS 8eneral state of health 6R chronological account3 anal*sis of an* s*$2to$s% 'include the

9 critical characteristics of an* s*$2to$( Als# n#te signi+icant negati,es'

+ Location : e s2ecific; as0 the 2erson to locate 2recisel* /here the 2ain is% Is the 2ainlocali


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-' PAST HEALTHChildhood illnesses3 serious or chronic illness3 accidents=inBuries3 o2erations3 hos2itali3 2ertussis3 and stre2 throat.#s0 a)out serious illnesses that $a* ha-e had aftereffects for the 2erson in late *ears%

+ Accidents/In!uries : #uto accidents3 fractures3 2enetrating /ounds3 head inBuries'es2eciall* if associated /ith unconsciousness(3 and )urns%

+ Serious/Chronic Illnesses : #sth$a3 de2ression3 dia)etes3 h*2ertension3 heart disease3"IV3 he2atitis3 sic0le+cell ane$ia3 cancer3 and sei+ra*fil$3 $a$$ogra$3 Pa2 test3 stool occult )lood3 seru$ cholesterol%

+ Allergies Note )oth the allergen '$edication3 food3 or contact agent such as fa)ric oren-iron$ental agent( and the reaction 'rash3 itching3 runn* nose3 /ater* e*es3 or $oreserious difficult* )reathing(% ,ith a drug this s*$2to$ should not )e a side effect )ut atrue allergic reaction%

+ Current )edications ?or all currentl* 2rescri)ed $edications3 note the na$e 'generic ortrade(3 dose3 and schedule A"o/ often do *ou ta0e it each da*. ,hat is it for. "o/long ha-e *ou )een ta0ing it. 7o *ou ha-e an* side effects. If not ta0ing it3 /hat is thereason *ou sto22ed ta0ing it. #s0 a)out non2rescri2tion=6TC drugs: as2irin3 -ita$ins3

)irth control3 antacids3 cold re$edies3 aceta$ino2hen% ?or an* 2ain relie-er as0 ho/$an* $illigra$s the 2erson ta0es% #s0 a)out her)al $edications%

-I' FA ILY HISTORYN#te .hich relati,e/s0 i+ p#siti,e "eart disease &&&&&&&&&&&&&&&&&&&& #llergies &&&&&&&&&&&&&&&&&&&&&"igh )lood 2ressure &&&&&&&&&&&&&&& #sth$a &&&&&&&&&&&&&&&&&&&&&&&&

Stro0e &&&&&&&&&&&&&&&&&&&&&&&&&& 6)esit* &&&&&&&&&&&&&&&&&&&7ia)etes &&&&&&&&&&&&&&&&&&&&&&&& #lcoholis$=drug addiction &&&&&&&&&&lood disorders &&&&&&&&&&&&&&&&&& Mental illness &&&&&&&&&&&&&&&&&&reast=o-arian cancer &&&&&&&&&&&&& Suicide &&&&&&&&&&&&&&&&&&&&&&&

Cancer 'other( &&&&&&&&&&&&&&&&&&& Sei


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7ra/ genogra$ noting si)lings3 2arents3 s2ouse3 children3 and grand2arents% Note ages3causes of an* deaths3 and 2resence of an* illnesses or fa$il*+related conditions%


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VII%RE-IE1 OF SYSTE S /234s at least +#r each s%ste$5 .rite Presence #r Absence #+ alls%$pt#$s' This secti#n is li$ite" t# patient state$ents an" s!67ecti,e "ata'

General O,erall Health State+ Present /eight 'gain or loss3 o-er /hat 2eriod of ti$e3 )* diet or other factors(3 fatigue3

/ea0ness or $alaise 'disco$fort(3 fe-er3 chills3 s/eats or night s/eats%

S8in+ "istor* of s0in disease 'eccessi-e )ruising3 rashor lesion%

Hair+ Recent loss3 change in te>ture% Nails: change in sha2e3 color3 or )rittleness%

o "ealth Pro$otion: #$ount of sun e>2osure; $ethod of self+care for s0in andhair%

Hea"+ #n* unusuall* fre1uent or se-ere headache; an* head inBur*3 di


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o "ealth Pro$otion: Perfor$s )reast self+e>a$3 including its fre1uenc* and$ethod used; last $a$$ogra$%

A illa+ Tenderness3 lu$2 or s/elling3 rash%

Respirat#r%+ "istor* of lung diseases 'asth$a3 e$2h*se$a3 )ronchitis3 2neu$onia3 T (3 chest 2ain

/ith )reathing3 /heein or 2ollution e>2osure%

o "ealth Pro$otion: Last chest +Ra* stud*3 T s0in test%

)ar"i#,asc!lar+ Chest 2ain3 2ressure3 tightness or fullness3 2al2itation3 c*anosis ')luish tint of s0in(3

d*s2nea on e>ertion 's2ecif* a$ount of e>ertion e%g%3 /al0ing one flight of stairs3/al0ing fro$ chair to )ath3 or Bust tal0ing (3 ortho2nea 'shortness of )reath /hen l*ingdo/n(3 2aro>*s$al nocturnal d*s2nea ' attac0s of se-ere shortness of )reath andcoughing that generall* occur at night( 3 nocturia 'need to /a0e u2 in the $iddle of thenight and urinate(3 ede$a 's/elling(3 histor* of heart $ur$ur3 h*2ertension3 coronar*heart disease3 ane$ia%

o "ealth Pro$otion: 7ate of last EC8 or other heart tests3 cholesterol screening%

Peripheral -asc!lar+ Coldness3 nu$)ness and tingling3 s/elling of legs 'ti$e of da*3 acti-it*(3 discoloration in

hands or feet ')luish red3 2allor3 $ottling3 associated /ith 2osition3 es2eciall* around feetand an0les(3 -aricose -eins or co$2lications3 inter$ittent claudication 'cra$2ing(3thro$)o2hle)itis 'infla$$ation of the /alls of the -eins associated /ith thro$)osis(3ulcers%

o "ealth Pro$otion: 7oes the /or0 in-ol-e long+ter$ sitting or standing. #-oidcrossing legs at the 0nees% ,ear su22ort hose.

Gastr#intestinal+ #22etite3 food intolerance3 d*s2hagia3 heart)urn3 indigestion3 2ain 'associated /ith

eating(3 other a)do$inal 2ain3 2*rosis 'eso2hageal and sto$ach )urning sensation /ithsour eructation(3 nausea and -o$iting 'character(3 -o$iting )lood3 histor* of a)do$inaldisease 'li-er or gall)ladder3 ulcer3 Baundice3 a22endicitis3 colitis(3 flatulence3 fre1uenc*of )o/el $o-e$ent3 an* recent change3 stool characteristics3 consti2ation or diarrhea3

)lac0 stools3 rectal )leeding3 rectal conditions 'he$orrhoids3 fistula(%o "ealth Pro$otion: Use of antacids or la>ati-es% '#lternati-el*3 diet histor* and

su)stance ha)its can )e 2laced here%(

(rinar%+ ?re1uenc*3 urgenc*3 nocturia3 'nu$)er of ti$es the 2erson a/a0ens at night to urinate3

recent change(; d*suria; 2ol*uria 'a lot( or oliguria 's$all a$ount(; hesitanc* orstraining3 narro/ed strea$; urine color cloud* or 2resence of he$aturia(; incontinence;histor* of urinar* disease '0idne* disease3 0idne* stones3 urinar* tract infections3

2rostate(; 2ain in flan03 groin3 su2ra2u)ic region3 or lo/ )ac0%o "ealth Pro$otion: Measures to a-oid or treat urinar* tract infections3 use of

Kegel e>ercises after child)irth%

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ale9Fe$ale Genital S%ste$+ Male: Penis or testicular 2ain3 sores or lesions3 2enile discharge3 lu$2s3 hernia%

o "ealth Pro$otion: Perfor$ testicular self+e>a$. "o/ fre1uentl*.+ ?e$ale: Menstrual histor* 'first 2eriod3 last 2eriod3 c*cle and duration3 an* a$enorrhea

'a)sence of $enstruation( or $enorrhagia 'hea-* )leeding during $enstruation(3 2re$enstrual 2ain or d*s$enorrhea '2ainful $enstruation=cra$2s(3 inter$enstruals2otting(3 -aginal itching3 discharge and its characteristics3 age at $eno2ause3$eno2ausal signs or s*$2to$s3 2ost$eno2ausal )leeding%

o "ealth Pro$otion: Last g*necologic chec0u2 and last Pa2 test%

Se !al Health+ Start off /ith AI usuall* as0 all 2atients a)out their se>ual health% Then as0: A#re *ou

2resentl* in a relationshi2 in-ol-ing intercourse. #re the as2ects of se> satisfactor* to*ou and *our 2artner. #re condo$s used routinel*. Is there an* d*s2areunia ordifficult=2ainful se> 'for fe$ale( or are there an* changes in erection or eBaculation 'for$ale(. #re there contrace2ti-es used. Is the contrace2ti-e $ethod satisfactor*. #re *oua/are of contact /ith a 2artner /ho has an* STI.

!sc!l#s8eletal+ Is there are histor* of arthritis or gout. In the Boints: 2ain stiffness3 s/elling 'location3

$igrator* nature(3 defor$it*3 li$itation of $otion3 noise /ith Boint $otion. In the$uscles: an* $uscle 2ain3 cra$2s3 /ea0ness3 gait 2ro)le$s3 or 2ro)le$s /ithcoordinated acti-ities. In the )ac0: an* 2ain 'location and radiation to e>tre$ities(3stiffness3 li$itation of $otion3 or histor* of )ac0 2ain or dis0 disease.

o "ealth Pro$otion: "o/ $uch /al0ing 2er da*. ,hat is the effect of li$itedrange of $otion on #7Ls such as groo$ing3 feeding3 toileting3 dressing. #re an*$o)ilit* aids used.

Ne!r#l#gic+ "istor* of sei


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VIII% ?UNCTI6N#L #SSESSMENT'includes #7L4s(

Sel+;Estee$9Sel+;)#ncept+ Education 'last grade co$2leted3 other significant training(3 financial status 'inco$e

ade1uate for lifest*le and=or health concerns(3 -alue+)elief s*ste$ 'religious 2ractices and 2erce2tion of 2ersonal strengths(%

Acti,it%9E ercise+ ATell $e ho/ *ou s2end a t*2ical da*% 3 Note a)ilit* to 2erfor$ #7Ls: inde2endent or

needs assistance /ith feeding3 )athing3 h*giene3 dressing3 toileting3 )ed+to+chair transfer3/al0ing standing3 or cli$)ing stairs% Is there an* use of /heelchair3 2rostheses3 or$o)ilit* aids.

+ Record leisure acti-ities enBo*ed and the e>ercise 2attern 't*2e3 a$ount 2er da* or /ee03$ethod of /ar$+u2 session3 $ethod of $onitoring the res2onse of the )od* to e>ercise(%

Sleep9Rest+ Slee2 2atterns3 da*ti$e na2s3 an* slee2 aids used%

N!triti#n9Eli$inati#n+ Record the diet )* a recall of all food and )e-erages ta0en o-er the 2ast J hours 'see

Ch2% !! for suggested $ethod of in1uir*(% AIs that $enu t*2ical of $ost da*s. 7escri)eeating ha)its and current a22etite% A,ho )u*s food and 2re2ares food. #re *our financesade1uate for food. ,ho is 2resent at $ealti$es. Indicate an* food allerg* orintolerance% Record dail* inta0e of caffeine% #s0 a)out usual 2attern of )o/el eli$ination

and urinating3 including 2ro)le$s /ith $o)ilit* or transfer in toileting3 continence3 use of la>ati-es%

Interpers#nal Relati#nships9Res#!rces+ A"o/ /ould *ou descri)e *our role in the fa$il*. "o/ /ould *ou sa* *ou get along

/ith fa$il*3 friends3 and co+/or0ers. #s0 a)out su22ort s*ste$s co$2osed of fa$il*and significant others: ATo /ho$ could *ou go for su22ort /ith a 2ro)le$ at /or03 *ourhealth3 or a 2ersonal 2ro)le$. % Include contact /ith s2ouse3 si)lings3 2arents3 children3friends3 organiing3 or is itisolating.

Spirit!al Res#!rces

+ ?aith: A7oes religious faith or s2iritualit* 2la* an i$2ortant 2art in *our life. 7o *ouconsider *ourself to )e a religious or s2iritual 2erson.

+ Influence: A"o/ does *our religious faith or s2iritualit* influence the /a* *ou thin0a)out *our health or care for *ourself.

+ Co$$unit*: A#re *ou a 2art of an* religious or s2iritual co$$unit* or congregation.+ #ddress: A,ould *ou li0e $e to address an* religious or s2iritual issues or concerns /ith

*ou.

)#ping an" Stress anage$ent

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+ T*2es of stresses in life3 es2eciall* in the 2ast *ear; an* change in lifest*le or an* currentstress; $ethods tried to relie-e stress and /hether these ha-e )een hel2ful%

Pers#nal Ha6its /ca++eine5 alc#h#l5 illicit9street "r!gs9prescripti#n a6!se0; A7o *ou s$o0e cigarettes '2i2e3 use che/ing to)acco(. #t /hat age did *ou start. "o/

$an* 2ac0s do *ou s$o0e 2er da*. "o/ $an* *ears ha-e *ou s$o0ed.o Record the nu$)er of 2ac0s s$o0ed 2er da* 'PP7( and duration% Then as03

A"a-e *ou e-er tried to 1uit. and A"o/ did it go. to introduce 2lans a)outs$o0e cessation%

; #s0 if 2erson drin0s alcohol% ,hen /as the last drin0. "o/ $uch did *ou drin0 thatti$e. In the 2ast da*s3 ho/ $an* da*s /ould *ou sa* that *ou dran0 alcohol. "asan*one e-er said that *ou had a drin0ing 2ro)le$.

o Cut do/n3 #nno*ed3 8uilt*3 and E*e+o2ener 'C#8E( test%If 2erson ans/ers *es to t/o or $ore3 *ou should sus2ect alcohol a)useand continue /ith $ore su)stance+a)use assess$ents% If 2erson ans/ersno3 as0 the reason for this decision% #n* histor* of alcohol treat$ent.In-ol-ed in reco-er* acti-ities. "istor* of a fa$il* $e$)er /ith

2ro)le$ drin0ing.; #s0 s2ecificall* a)out 2rescri2tion 2ain0illers or other illicit=street drugs% Indicate

fre1uenc* of use and ho/ use has affected /or0 or fa$il*%

En,ir#n$ent9Ha


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NU !!=S2ring !F="ealth "istor*

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