FAR EASTERUNIVERSITY
INSTITUTE OF NURSING AHSE
HEALTH HISTORY
A. BIOGRAPHIC DATA
1. Name
2. Address
3. Age
4. Gender
5. Date of Birth – Age as of Last Birthday
6. Place of birth
7. Ethnic group (Minority)
8. Primary Dialect spoken - Only one!!
9. Marital Status
10. Educational
11. Occupation (not student)
12. Religious orientation – Religious Sect
13. Health Care financing and usual source of medical care – Where do you get financial Health
14. Income (Allowance)
B. PAST HEALTH HISTORY
1. Childhood diseases (Specify immunizable and chronic(relapse) (significant) diseases, Age when disease acquired, interventions done, residual effects of disease, be careful with spelling of disease)
2. Immunizations- name and doses, consider secondary sources)
3. Allergies • drugs • food • others - description of reaction, treatment regimen, compliance, frequency of attacks
4. Accidents and Injuries – Specify minor and major injuries that required medical attention
5. Hospitalizations and medications (include Self-prescribed)- Specify year, disease, outcome
7. Foreign Travel – Specify all travels to any countries made during the past year
8. Local Travel – to identify visit endemic Areas during the past years
C. FAMILY HISTORY OF ILLNESS (insert genogram)
1. Health and ages of parents, siblings, children, or ages at death and causes illness in the family similar to the patient’s – IF DATA IS UNVAILABLE, WRITE “DATA UNAVAILABLE.”
2. Presence of any hereditary diseases: (FOCUS ON HEREDITARY DISEASES) familial incidence of heart disease, rheumatic fever? Tuberculosis? Diabetes Mellitus? Mental illness?
3. Others? SUCH AS PRESENCE OF HYPERTENSION, CONGENITAL CONDITIONS
FUNCTIONAL HEALTH PATTERNS
D. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN
1. How has the general health been? How do you rate your own health? – MAKE SURE TO EXPLAIN THE RATING DONE BY THE CLIENT.
2. HOW DO YOU PERCIEVE A HEALTHY PERSON, DO YOU CONSIDER YOURSELF AS HEALTHY PERSON? What do you consider healthy about you? What are your health goals? WHAT ARE YOUR METHODS TO ACHIEVE THEM?
3. What are THE PRACTICED traditional concepts of health and illness? Beliefs and practices? U MAY PROVIDE EXAMPLE
4. Do you have routine physical examination? If yes how often? IF NO, EXPLORE REASONS FOR NOT HAVING A ROUTINE EXAMINATION OR FOR STOPPING AND
5. Perform self breast examination? (female) DESCRIBE. FOR VALIDATION, ASSESS SKILL DURING PA.
6. In the past year how many times have you seen a health care provider? For what reasons?
7. In the past, has it been easy to find ways to follow things nurses/doctors suggest? CITE INSTANCES WHEREIN YOU ARE ABLE OR NOT ABLE TO FOLLOW THESE INTERVENTIONS. EXPLORE REASONS WHY UNABLE TO FOLLOW SUGGESTIONS.
8. What safety practices do you follow? HAZARDS
9. Most important things to keep health? You think these things will make a difference to health/ (include family/ folk remedies if appropriate). DESCRIBE HEALTH PROMOTION AND DISEASE PREVENTION ACTIVITIES
10. Personal Hygienic practices: Describe how do you take care of your body? Bath, hand washing, trimming of fingernails, wearing of slippers, use of deodorant/cologne, brush teeth, flossing, dental visits? NO NEED TO SPECIFY BRANDS OF SHAMPOO, DEODARANT
11. Substance use; Use of cigarette, alcohol, drugs? Kind, amount, frequency? Reasons? Aware of effects? Passive smoking?
12. Environmental condition: adequacy of lighting and ventilation,
13. Environmental sanitation practices: water supply, toilet facilities, waste management, food handling and storage, presence of vectors, health hazards – Incidence of water and food borne diseases, include parasitism and dengue
14. Describe the place you are currently living in. *include the amount of space, ventilation, sounds, odors* (If the client is living in a dormitory, kindly ask also for a description of the house that he/she lives in if he/she is not in a dormitory.)
16Describe the community that you live in. (in terms of facilities and amenities).
17. What are the municipal service/s do/does your community offer? (e.g. trash removal, fumigation)
18. Describe the ventilation of the place that the client is currently living in.
19. Describe the usual clothing that he/she uses indoors/outdoors.
20. Are there environmental contaminants (pesticides, chemical, and tobacco smoke) present in the home/school?
21. Describe household hygienic practices.
22. What are his/her usual activities done outdoors?
23. How does he person describe his/her current health?
24. What does the person do to improve or maintain his/her health?
25. What does the person know about the links between lifestyle choices and health?
26. How big a problem is financing healthcare for this person?
27. If this person has allergies, what does he/she do to prevent problems?
28. Have there been any important illnesses or injuries in this person’s life?
29. How does he feel about the health concern that he/she is experiencing? (note any non-verbal or verbal communication; are the client’s statement relevant to the situation?)
30. Describe how you take care of your body.
31.Does he/she have any pets? If so, what kind?
32. What kind of appliances and equipment does his/her family have at home?
E. NUTRITIONAL AND METABOLIC PATTERN
1. 3 day diet recall (on a typical day, feasts not included) - TYPE OF FOOD,QUANTITY (AMOUNT AND SIZE), METHOD OF COOKING, INCLUDE FLUIDS,TIME OF EATING
2. SUPPLEMENTS TAKEN, DOSES, PRESCRIBE
3. What is your knowledge ABOUT proper nutrition? ASK IF CLIENT HAS PROPER NUTRITION
4. Food likes and dislikes?
5. Food preparation? – Usual
6. Where do you eat?
7. Whom do you usually eat with?
8. Food budgeting (daily)?
9. Sudden change in weight (loss/ gain)?Amount?
10. Appetite?
11. Food or eating discomforts? Diet restrictions?
12. Heal well or poorly?
13. Exposure to hot and cold environment?
14. Knowledge about basic nutrition? Awareness on healthy food and fluid choices?
15. Knowledge about dental health?
16. Skin problems? Lesions? Dryness?
17. Dental problems? (ASK CLIENT’S PERCEPTION ABOUT THE POSSIBLE CAUSESOF DENTAL PROBLEMS. ASK HOW THESE PROBLEMS AFFECT NUTRITION.)
F. ELIMINATION PATTERN
1. Bowel elimination pattern.When do you usually have a bowel movement Frequency? Do you usually go to the toilet when there is an urge to defecate? Any recent environmental changes? Characteristics (color, texture, odor shape and consistency)? Any changes of these recently? Discomfort/pain? Any significant change in the usual pattern?
2. What problems have you had or do you now have with your bowel movements (constipation, diarrhea, excessive flatulence, seepage, or incontinence) When and how often does it occur? What do you think causes it (food, fluids, exercise, emotions, medications, diseases, surgery)? What have you tried to solve the problem, and how effective was it? Do you experience any increase in abdominal pressure/ feeling of rectal fullness/pressure
3. Knowledge regarding normal defecation pattern? Knowledge to maintain normal defecation pattern? What routines or practices do you follow to maintain your usual defecation pattern? Is it Effective? How do you think these practices affect your defecation pattern? Do you use natural aids such as specific foods or fluids, laxatives, or enemas to maintain elimination? What foods do you believe affect defecation? Are you experiencing any stress? Do you think it affects your defecation pattern? How?
4. Urinary elimination pattern. Describe. Frequency? Has this pattern change recently? Do usually urinate whenever you feel the urge? Any feelings of urgency? Hesistancy? Characteristics (color, clarity, odor)? Discomfort/pain? Problems in control? (Approximated amount in mL per day)? Passage of small amounts of urine? Voiding at intervals that are more frequent? Trouble getting to the bathroom in time or feeling an urgent need to void? Difficulty starting urine stream? Frequent dribbling of urine or feeling of bladder fullness associated with voiding small amounts of urine? Reduced force of stream? Accidental leakage of urine? If so when does it occur (when coughing, laughing, or sneezing; at night or during the day)? Past urinary tract illness such as infection of the kidney, bladder or urethra; urinary calculi; surgery of kidney, ureters, or bladder?
5.Knowledge on normal urinary elimination pattern. Explore client’s knowledge and practices on how to achieve normal urinary elimination pattern? How it affect the urinary elimination pattern
6. Excessive perspiration? Odor problems?
G. ACTIVITY-EXERCISE PATTERN
1. Make a 7-day activity diary – be specific with the activities (such as bathing, brisk-walking, trimming nails)
2. Kind of physical activity do you engage in?
Exercise pattern – regularity? how many times you engaged in a week? When started? Describe the exercise pattern.
Intensity – use talk test to determine intensity, Duration – cumulative 30 mins daily, not necessarily continuous.
3. Are you satisfied with the amount of exercise do you get?
4. Sufficient energy for completing desired required activities?
5. Spare time (leisure activities?) Enough resources for leisure activities? Satisfaction? Specify
6. What are your usual hobbies? Are you able to find time and allot resources for your hobbies at present?
7. Any recent changes in your activities? What brought about such changes?
8. Do you experience boredom at times? In which instances?
9 .What materials, equipment or resources for recreation and diversional activity are present in your immediate environment?
10. Have there been changes in your diversional activity? Please elaborate. How are you adapting to changes? Is there sudden weight loss/ gain?
Observe for:
Flat affect
Disinterest
Inattentiveness
Restlessness
Crying
Withdrawal
Hostility
11. If you are going to gauge the stress level you are experiencing right now, on a scale of 1-10 (10 being the most stressful experience and 1 being the most tolerable stress level), how do you rate your stress level? Explain the reason.
12. What factors in the environment contribute to your experience of fatigue? (noise, lights, humidity, temperature)
13. Have there been recent negative life events that had their impact on your day-to-day activities? Please elaborate on them. (sleep deprivation, pregnancy, disease state, malnutrition, anemia, poor physical condition etc.)
14. Most of the time, do you easily get tired? Do you feel that you can easily and immediately restore energy after resting?
15. Do you feel that you have more physical complaints now than before? What are those?
Observe for:
Lack of energy
Listlessness
Drowsiness
Compromised concentration
Disinterest in surroundings
Introspection
Decreased performance (accident-prone)
16. Do you desire to enhance your independence in maintaining life/ health/ personal development/ well being through improvement of your physical activities? Please elaborate.
17. Do you desire to enhance self-care/ knowledge for strategies for self-care/ responsibility for self-care? Please elaborate.
18.Is there a risk for limitation in independent physical movement? Specify.
19. What functional level is s/he capable of achieving?
20. Are there medications taken that might affect physical mobility?
21. Are there prescribed movement restrictions?
22. Any discomfort in movement?
23. Any sensoriperceptual changes/impairment?
24. Any risk for neuromuscular impairment?
25. Is there risk for decreased muscle strength?
26. Is there reluctance to initiate movement?
27. Is there a risk for loss of integrity of bone structure/strength?
28. Any potential for developmental delay?
29. Presence of joint stiffness or contractures?
30. Any limitation in cardiovascular endurance?
31. Are there cellular metabolism problems?
32. Any cultural beliefs that might affect activities?
33. Is there a lack of knowledge regarding value of physical activity?
34. Is there decreased muscle strength?
35. Is there alteration in cellular metabolism
36. Any neuromuscular impairment?
37. Is there reluctance to initiate movement?
38. What are activities pertaining to interests that cause low physical activity?
39. Is there presence/absence of motivating factors for physical activity? What are those?
40. Any resources or lack if it that predispose said physical activity?
41. What are the usual activities for recreation?
H. SLEEP AND REST PATTERN
1. How many hours of sleep do you usually have? What time do you usually sleeps?wakes up?
2. Describe your feelings after waking up? Refreshed/ fatigued/ lethargic? Do you always feel that way?
3.Adequacy of energy to perform daily task? To finish them?
4.Do you usually feels tired, exhausted, feels like lacking in energy? Its degree?
Can you concentrate on the task at hand?
5.Do you still find the time to do/ engage with other activities, such as churchworks, household chores, dating, going out with friends, spending time with loved ones..?
6. Do you usually engage yourself in self reflection? How often?
7. Has there been any notable changes between your past and present set of activities?When did it start?
8. Any change in the pattern of sleep? Explore client’s perception regarding the possible reasons for this. Should be maintained for one week,
9. Describe sleeping environment. Any problems? Concerns?
10. Any problem falling sleep?
11. What helps you sleep? (back rub, music or warm milk? Do you take sleep medications?)
12. If applicable, what time of the day do you usually take naps? For how long?
13Describe the sleeping environment. Ventilation?.sleep with or without lights? Any episodes of prolonged awakening?
14. How would you describe your usual sleep pattern?disrupted?continous?having difficulty falling asleep?how long before you fall asleep?
15. Do you usually wake up at the same time?
16. Do you experience mood swings?how often?
17. Are you living or sleeping with family or friends or your living alone?
18. Are there daytime activities that need to be extended till night?Has there been a change in the sleeping pattern since the change in age?Describe.
19. Lately were you able to fulfill your responsibilities fully?
21. Has there been a prolonged use of drugs that affect sleep?dietary antisoporifics?(caffeine, alcohol, stimulating substances, late night evening tv watching
22. Large evening meals,?What are the physical discomforts that affect a person’s sleep? Psychological? Diseases that affect the continuity of sleep?
23. Presence of sustained unrelieved pain? Sleep-related enuresis? Having or experiencing nightmares? Sleepwalking?sleep terror?
24. Lifestyle that is done at night? Presence of current or recent or recent illness?Client’s habit of increased fluid intake in the evening?
25. Any loss in the present or the past? Describe grieving process?
26. Presence of change of work pattern?
27. What other forms of relaxation do you engage in aside from sleeping?
Include Sleep diary (refer to Fundamentals of Nursing by Kozier 8th edition)
I. COGNITIVE-PERCEPTUAL PATTERN
Perform APGAR scoring assessment for newborns.
APGAR Scoring System Sign
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Signs
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Scoring
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0
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1
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2
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Heart Rate
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Absent
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Slow (below 100 per min.)
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Above 100 per minute
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Respirations
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Absent
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Slow irregular
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Regular rate, crying
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Muscle Tone
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Flaccid
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Some flexion of the extremities
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Active Movements
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Reflex Irritability
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None
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Grimace
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Cries
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Color
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Body pale cyanotic
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Body Pink (For African American babies, pink mucous membranes), Extremities blue.
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Body completely pink, pink mucous membranes in African American babies
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Perform Development Tests for Children (0-6 years old) MMDST
* Assess for coherence, orientation of time, person and place, speech, relevance and logical sequence of thoughts.
*Assess for pain and appropriate response, grimaces. Take note of exaggerated responses
*Assess for levels of consciousness, reflexes, and psychomotor activity .
1. Are you able to read, write or speak? Any difficulty reading, writing or speaking? What is done? Effective? Satisfied?
2. Any significant changes in the different senses of the body? Assess for the nature of the medications taken if prescribed or not by a physician.
3. Vision: Any difficulty reading? Are there any changes in vision? What do you think caused these changes? Any use of medications for the eyes? What was done? Effective? Satisfied? Do you wear glasses or contact lenses? When was the eyes last checked? How often do you have your eyes examined?
4. Hearing: Any difficulty hearing? Are there any changes in hearing? What do you think caused these changes? Any use of medications for the ears? What was done? Effective? Satisfied? Any use of hearing aids? When was the ears last checked? How often do you have your ears examined?
5. Smell and Taste: Any change in smelling? Any change in taste? What do you think caused these changes? Any use of medications? What was done? Effective? Satisfied? Oral examinations? How often do you have oral check-ups?
6. Touch: Any change in the sense of touch? What do you think caused the changes these changes? Any use of medications? What was done? Effective? Satisfied?
7. Pain: Any pain? Pain scale? Characteristics? When occurred? What type of activity experienced? How does it affect you? How do you manage pain? Effective? Satisfied?
8. Any changes in memory? How does it affect you? What do you think caused these changes? Any use of medications? What was done? Effective? Satisfied?
9. Easiest way to learn things? What are your learning goals?Any difficulties or hindrances to learning? What was done? Effective? Satisfied?
10. How would you describe your performance in school/ work? What motivates you in school/work? Any problem in school/work? How do you solve them? Effective? Satisfied? Alternatives? Explore factors that could have direct or indirect effects to the client.
J. SELF-PERCEPTION AND SELF-CONCEPT PATTERN
1. How do you describe yourself? Most of the time, feel good (not so good) about yourself?
2. Changes in your body or the things you can do? How do you consider them
3. Did you notice any physical changes or alterations? If applicable, how did it affect the way you look at yourself? Explore client’s feeling about these changes. Explore as well the impact of this to oneself and with self in relation to other people.
4. How do you see yourself in relation to other people? (better than, equal to or less than)
5. How do you express your thoughts and feelings to others? Explore its effectiveness.
6. What are your goals in the next five years? How do you plan to achieve them?
7. Describe the characteristics of a person whom you would like to be with. Explore for the reasons why.
8. What type of mood are you usually in? (calm, depressed, pleasant, happy, excited, agitated) Explore factors which could contribute to sudden changes in mood.
9. What are the things that make you angry? Annoyed? Tearful? Anxious? Depressed? Explore client’s knowledge and practices in dealing with these emotions.
10.In what way do you express yourself during mood changes? How does it affect your relation to other people? Explore.
11. Are you satisfied with your usual mood? Reason?
12. What kind of person are you? (positive/negative) Elaborate.
14. How would you rate your self esteem? (1 – 10; with 10 the highest)
15. What are your problematic moods? When do you feel depressed> Guilty? Unreal? Apathetic? Separated from the world? Detached?
16. Are you a nervous person? Describe.
17. Are your feelings easily hurt? Why? How do you react on it?
18. Has there been any major change in your life lately? Please leaborate on this/these change/s.
19. Do you feel regretful, scared, distressed, apprehensive or fearful lately? What makes you feel so? Does it affect you in any physical/ physiological way? How?
20. Do you have goals, values or needs in life that are in conflict at present? What? How is it conflicted?
21. Do you feel stressed lately? What would you say is causing such? How does it affect you?
22. Do you feel like you are different from how you view yourself? Mat it be in appearance or function? If so, what is different? How does it affect you?
23. Are you in any force to change a certain lifestyle you desire? Can you elaborate on this.
24. Do you ever feel rejected by others? How?
25. Do you feel in anyway helpless, hopeless or powerless? How?
26. Already covered by questions on anxiety
27.If you have a problem, do you feel like you are incapable of changing things to be better? If so, do you think no one can help with this? Please elaborate how?
28. Would you consider that there is still a possibility that you can get help? If so, would you consider yourself to be part of it?
K. ROLE-RELATIONSHIP PATTERN
1. Live alone? With family? (illustrate family diagram) Family structure? (Accdg to membership: Nuclear, Extended, Single parent,etc.; Accdg to Authority: Patriarchal, Matriarchal, Egalitarian,Democratic ) Significant people in life? (What role do they (SO) play in the client’s life)
2. Describe relationship to each/other member of the family; how do you feel about them? When with them, do you often feel happy, hurt, insecure, rejected, misunderstood, unloved, lonely? Note any observable conflicts between members
3. Role/s assumed in the family. Fulfilled/ Any difficulty in performing your role/s? Why? (Who plays as the role model in the family? Who guides you in doing your role/s) Any unrealistic role expectations? Are the resources/your energy enough for you to perform your role/s?
4. Any family problems you have difficulty handling? (Alcohol/substance abuse by a member, any Physical Disabilities of a member/presence of illness, problems in behavior, decisional conflicts) Explore.
5. How does your family usually handle problems? Effective or not? Cite examples (ways of coping), any incidence of inappropriate expression of anger, blaming, criticizing, verbal abuse, lying) How do you address such? Effective?
6. Family dependent on you for things? If appropriate? How manage?
7. Any recent (past year) situational crises experienced by the family? (economic, change in roles, illness, trauma, disabling/expensive treatment); Developmental crises? (loss/gain of family member, adolescence, leaving home for college); Explore how did this/these affect the family processes/impact to the family
8. What do you think of voicing opinions to family? (Do you confide your problems to your family/ do you have open communication?) Friends?
9. Who initiates activities with family or with friends?
10. What are usual family activities? Any disruption in family rituals/activities? Explore.
11. Belong to social groups? Close friends? Feel lonely frequently? Feel insecure? Are you satisfied with your personal relationships? When in the company of others, how do you think should one behave? Social values? ( Observe for any unaccepted social behavior, sad affect, no eye contact)
12. How do you express your feelings or thoughts to others? (any difficulty expressing your thoughts/feelings?)
13. Are things generally go well with you at work? (school/college)? Are there any problem in work/school that influence your health?
14. Income/allowance sufficient for needs? Any financial problems or concerns?
15. Any recent change/s or perceived change/s in your environment (transfer from one place to another or possibility of relocation, noise) Explore effects to the family;
16. Feel part of (or isolated in) neighborhood where living? Any language barrier? Lack of adequate support system? Insecurity?
L. SEXUALITY-REPRODUCTIVE PATTERN
Sexuality
- How do you express yourself in relation to your gender?
- Are you comfortable with the gender to which you belong?
- Have you experienced some difficulty in regard to this?
- How would you describe your relationship with those of the opposite sex?
- Who do you prefer going with, people you more comfortable with: those from the same or opposite sex?
- Right now, is there someone special whom you consider significant in life?
- (If applicable) Is your relationship with him or her mutual and/or satisfying?
Reproductive
- (For a male client) Have you already undergone circumcision?
- Is there any discomfort or problem with regard to your genitalia that you would like to share or is significant that we note?
- Do you know how to perform testicular self-examination (TSE)? If so, when or how often do you perform this one?
- (For a female client) When did you have your first menstruation (menarche)?
- When was your last menstrual period? Please describe the duration, (amount) number of pads used per day, any associated discomfort and measures that would help relieve this (if any).
- Do you know how to perform breast self-examination (BSE)? If so, when or how often do you perform this one?
- (For both male and female clients) If there are reproductive health concerns, do you feel the need or at least make it a point to visit or consult a health care provider? If so, what are the usual reasons why you seek medical consultation?
- (If applicable) Do you also engage in sexual activity? (If appropriate, please ask if it’s done solely with his/her partner or there are other people he/she prefers having sex with?
- If so, how would you describe the satisfaction you get from such activity?
- (If applicable) Do you make use of contraceptives or other methods of family planning (if married)?
M. COPING-STRESS TOLERANCE PATTERN
1. Describe a stressful event for you?
2. How do you handle stress or pressure? Effective? Satisfied? Why/why not?
3. Tense a lot of time? What helps? Use of any medicine? Drugs? Alcohol?
4. Who’s most helpful in talking things over? Available to you now?
5. Any big changes in your life in the last year or two?
6. When (if) you have big problems (any problems) in your life, how do you handle them?
7. Most of the time, is this (are these) way(s) successful?
8.How do you usually cope with stressful situations? when faced with a stressful problem, do you see yourself having full control of the situation?
9. How do you handle stress or pressure? Is it easy for you to admit problems, mistakes or weaknesses? Are you usually defensive when being slighted? Explore. Give situations or scenario indicating defensive behavior.
10. How do you react to criticisms, whether slight or major criticisms?
11. How do you react to failures? How do you react when somebody offers you help or assistance?
You may observe a client’s behavior when working with peers and look for signs of being
