Obtain a comprehensive health history of a chosen patient/family member/lab partner to include

Obtain a comprehensive health history of a chosen patient/family member/lab partner to include:

-Reason for Seeking Care

-HPI

Present Health Status

-Past Health History

-Family History

-Personal and Social History

Family and Social Relationships

-Diet and Nutrition

-Functional Ability

-Mental health

-Substance, Alcohol and Illicit Drug use

-Health Promotion Practices

-Environment

-Review of Systems

_Clinical Judgement (Recognize Cues, Analyze, Problem List)

 

Date	Name	Preferred name	Sex Male Female	Gender Identity Male Female Both Neither
Date of birth	Age	Race/Ethnicity	Religion	Language(s)
Marital status S M D W	Occupation

 

REASON FOR SEEKING CARE (Presenting problem) 

 

 

 

 

 

HISTORY OF PRESENT ILLNESS

Symptom Analysis of Presenting Problem (Onset, Location, Duration, Characteristics, Aggravating factors, Related symptoms, Treatment, Severity)

 

 

 

 

 

 

PRESENT HEALTH STATUS 

Describe your current health conditions.

 

 

 

How long have you had these conditions?

 

 

 

 

 

How have these health conditions affected your daily activities?

 

 

 

 

What medications or supplements do you take? (Include prescription, over-the-counter, herbs, and vitamins) (Document if no medications or supplements are taken)

 

Name of Drug/Supplement	Dosage/Frequency	Last Dose Taken	Reason for Taking

 

 

 

 

 

Describe any medical treatments you are receiving (e.g., breathing treatments, dialysis, wound dressing): (Document if no medical treatments are received)

 

 

 

 

 

 

Describe any allergies to medications, foods, medical products (e.g., latex, contrast, tape), or things in the environment. Describe your symptoms and their frequency. (Document if there are no allergies)

 

 

Allergic To	Reaction and frequency

 

PAST HEALTH HISTORY

Childhood Illnesses (Check all that apply):

Measles ❏	Mumps ❏	Rubella ❏	Chickenpox ❏
Pertussis ❏	Influenza ❏	Ear infections ❏	Throat infections ❏
Other (describe) ❏

 

 

 

List previous medical conditions, surgeries, hospitalizations, or injuries. (Document if none apply)

Name and Type	Date	Residual Problems

 

 

Immunization	Date/s	Immunization	Date/s
Diphtheria, tetanus, acellular pertussis (DTaP)		Haemophilus influenzae type b (Hib)
Hepatitis A (HepA)		Hepatitis B (HepB) Influenza (IIV)
Human papillomavirus (HPV)		Influenza live attenuate vaccine (LAIV)
Inactivated poliomyelitis (IPV)		Meningococcal serogroup B (MenB)
Meningococcal serogroups A, C, W, Y (MenACWY)		Pneumococcal conjugate vaccine (PCV13)
Measles, mumps, rubella (MMR)		Zoster recombinant (RZV)
Pneumococcal polysaccharide vaccine (PPS23)		Rotavirus (RV)
Rotavirus (RV)		Tetanus toxoid (Td)
Tetanus, diphtheria, acellular pertussis (Tdap)		Varicella (VA)
Zoster live (ZVL)		Other

 

.

Last Examination	Date	Outcome
Physical
Vision
Dental
Other
Women Only
Pap Test
Mammogram
Men only
Prostate Exam

 

 

 

 

Obstetric history

Last menstrual period (LMP)	Date	Outcome
Pregnancies	Date	Gravida (number of pregnancies) ________ Para (number of births) ________ Abortion/miscarriage ________

 

 

FAMILY HISTORY

(Document age and current health of family members. If deceased, indicate age and cause of death.)

 

Person	Age	Current Health	Person	Age	Current Health
Mother			Father
Sister			Brother
Sister			Brother
Daughter			Son
Daughter			Son

 

 

Draw a genogram for your lab partner’s family history.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL AND PSYCHOSOCIAL HISTORY 

Personal Status 

 

How would you describe yourself? or How do you feel about yourself?

 

 

 

 

Describe your cultural/religious affiliations and practices.

 

 

 

 

 

Describe your education, occupational history, and work satisfaction.

 

 

 

 

 

Describe your perception of adequate time for leisure and rest, hobbies and interests.

 

 

 

 

 

 

Family and Social Relationships 

Describe your satisfaction with interpersonal relationships including significant others, individuals in home, and your role within family.

 

 

 

 

 

 

Describe the state of health of these individuals. Describe social interactions with friends, social organizations, or religious groups.

 

 

 

 

 

 

Diet/Nutrition 

Describe your appetite, typical food and fluid intake, and caffeine intake.

 

 

 

Do you have any dietary restrictions or food intolerances?

 

 

 

Have you had any changes in appetite or weight; changes in taste of food; problems while eating, e.g., indigestion, pain, difficulty chewing or swallowing? If yes, describe.

 

 

 

Have you had experiences with overeating, sporadic eating, or intentional fasting? If yes, describe

 

 

 

Functional Ability 

Do you need any assistance performing any of the following activities?

Dressing	Toileting	Bathing	Eating	Ambulating
Shopping	Cooking	Housekeeping	Managing finances

 

†If unable to perform independently, describe.

 

Mental Health

Describe your sources of stress. How do you cope with these stresses?

 

 

 

Have you had feelings of anxiety, depression, irritability, or anger? If yes, describe.

 

 

Tobacco, Alcohol, and Illicit Drug Use 

Alcohol intake: Y ❏ N ❏	Type:                                  Frequency:
Illicit drug use: Y ❏ N ❏	Describe:
Tobacco use:   Y ❏ N ❏	Type:                                  Daily use:

 

 

Health Promotion Practices 

 

• What activities do you perform regularly to maintain your health?

Exercise (type/frequency):
Stress management:
Sleep habits:
Use of seat belts:
Other:

 

 

 

 

 

Environment (Include living and work environments)

Describe actions do you take to main your environmental safety? (Circle hazards below and add others as warranted.)

 

Potential hazards within home	e.g., lack of fire or smoke detectors, poor lighting, steep stairs, inadequate heat, open gas heaters, inadequate pest control, violent behaviors, firearms
Potential hazards within neighborhood	e.g., noise, water or air pollution, heavy traffic, overcrowding, violence, firearms, sale/use of street drugs
Potential hazards within work environment	e.g., inhalants, noise, heaving lifting, machinery, psychological stress
Any travel outside the United States	Describe locations and dates

 

 

 

 

 

 

 

 

 

 

 

 

 

REVIEW OF SYSTEMS

Remember to ask questions using lay terms the patient understands, but document using medical terminology. For example, ask the patient if he has shortness of breath; if he says “yes,” perform and document a symptom analysis and document that the patient “reports dyspnea.”

Check all boxes that apply and add additional data below each section.

Document if no symptoms are reported.

 

General Symptoms
Pain ❏	Fatigue ❏	Weakness ❏	Fever ❏
Problems sleeping ❏	Unexplained changes in weight ❏
Additional data:

 

 

 

Integumentary Systems
Skin lesions (wounds, sores, growths) ❏	Additional data: Excessive dryness ❏	Excessive sweating or odors ❏	Changes in skin temperature, texture, color ❏
Change in a mole ❏	Sore that does not heal ❏	Rashes ❏	Itching (pruritus) ❏
Frequent bruising ❏	Changes in amount, texture, distribution of hair ❏	Hair loss (alopecia) ❏	Itching scalp ❏
Changes in texture, color, or shape of nails ❏	Use of sunscreen ❏	Skin self-examination ❏	Types and frequency of nail care ❏
Additional data:

 

 

 

Head
Headaches ❏	Significant trauma ❏	Dizziness ❏	Fainting (syncope) ❏
Use of protective head gear ❏
Additional data:

 

 

Eyes
Discharge❏	Redness ❏	Itching (Pruritis) ❏	Excessive tearing ❏
Eye pain (Ophthalmalgia) ❏	Change in vision ❏	Difficulty reading ❏	Blurred vision ❏
Sensitivity to bright lights (Photophobia) ❏	Blind spots ❏	Floaters ❏	Halo around lights ❏
Double vision (Diplopia) ❏	Do you wear eyeglasses? ❏	Do you wear contact lenses? ❏	Use protective eyewear? ❏
Additional data:

 

 

 

 

Eyes
Ear pain (otalgia) ❏	Excessive earwax  ❏	Discharge ❏	Recurrent infections ❏
Decreased hearing ❏	Sensitivity to noises ❏	Ringing in the ears (tinnitus) ❏	Use of hearing device ❏
Protect ears from excessively loud noises ❏
Additional data:

 

 

Nose, Nasopharynx, Sinuses
Nasal discharge ❏	Nose bleeds (epistaxis) ❏	Sneezing ❏	Nasal obstruction ❏
Sinus pain ❏	Postnasal drip ❏	Change in ability to smell ❏	Snoring ❏
Additional data:

 

 

 

 

 

Mouth/Oropharynx
Sore throat ❏	Tongue or mouth lesions (abscess, sore, ulcer)❏	Bleeding gums  ❏	Dental prosthesis (dentures, bridges) ❏
Altered taste❏	Difficulty swallowing (dysphagia) ❏	Trouble chewing ❏	Change in voice ❏
Oral hygiene practice (frequency of brushing/flossing) ❏
Additional data:

 

 

Neck
Lymph Node Enlargement❏	Edema or mass in neck ❏	Neck pain  ❏	Neck stiffness/limitation in movement ❏
Additional data:

 

 

Breast
Pain ❏	Swelling (edema) ❏	Lumps or masses ❏	Breast dimpling  ❏
Nipple discharge ❏	Change in nipples ❏
Additional data:

 

 

Respiratory System
Cough, nonproductive or productive ❏	Coughing up blood (hemoptysis) ❏	Frequent colds ❏	Shortness of breaths (dyspnea) ❏
Night sweats ❏	Wheezing ❏	High pitched, musical sound when breathing (stridor) ❏	Pain with breathing (inspiration/ expiration) ❏
Handwashing frequency ❏	Tuberculosis screening ❏	Smoking cessation ❏	Reducing secondhand smoke ❏
Additional data:

 

 

 

Cardiovascular System
Sensation of heart fluttering or racing (palpitations) ❏	Chest pain ❏	Shortness of breath (dyspnea) ❏	Difficulty breathing unless sitting up (orthopnea) ❏
Periodic shortness of breath during sleep (paroxysmal nocturnal dyspnea) ❏	Coldness in extremities ❏	Difficulty reading ❏	Swelling (edema) of hands or feet ❏
Varicose veins ❏	Leg pain with activity not relieved by rest (rest pain) ❏	Leg pain with activity relieved by rest (intermittent claudication) ❏	Abnormal sensation in extremities (paresthesia) ❏
Changes in color of extremities ❏	Limit salt and fat intake ❏	Blood pressure screening ❏
Additional data:

 

 

Gastrointestinal System
Pain ❏	Heartburn ❏	Nausea/vomiting ❏	Vomiting blood (hematemesis) ❏
Yellowing of sclera/skin (jaundice) ❏	Increased abdominal size due to fluid accumulation (ascites ❏	Changes in usual bowel habits ❏	Painful defecation ❏
Passing gas (flatus) excessively ❏	Change in color or consistency of stools ❏	Constipation) ❏	Diarrhea ❏
Blood in stools (hematochezia) ❏	Hemorrhoids ❏	Dietary analysis ❏	Colon cancer screening
Additional data:

 

 

 

Urinary System
Changes in color, contents, or odor of urine ❏	Difficulty initiating urine flow (hesitancy) ❏	Repeated need to urinate (frequency) ❏	Sudden, almost uncontrollable need to urinate (urgency) ❏
Change in urine stream ❏	Excessive urination during the night (nocturia) ❏	Pain with urination (dysuria) ❏	Pain in back between ribs and ilium (flank pain) ❏
Blood in urine (hematuria) ❏	Inability to control urination (incontinence) ❏	Excretion of abnormally large volumes of urine (polyuria) ❏	Decreased urine output (oliguria) ❏
Plan to prevent urinary tract infections ❏	Performing Kegel exercises ❏
Additional data:

 

 

Reproductive System
Male	Lesions ❏	Pain in penis or testicles ❏	Masses in penis or testicles ❏	Penile discharge ❏
	Hernia ❏
Female	Lesions ❏	Pain ❏	Vaginal discharge/ odor ❏	Absent menstruation (amenorrhea) ❏
	Excessive menstruation (menorrhagia) ❏	Painful menstruation (dysmenorrhea) ❏	Irregular menstruation (metrorrhagia) ❏	Pelvic pain ❏
Sexual Activity
Are you currently involved in a sexual relationship(s)?	❏ No ❏ Yes   Is the nature of the relationship heterosexual, homosexual, or bisexual?
What is the type and frequency of sexual activity?	Type: ❏   Vaginal ❏.  Anal    ❏Oral.   ❏Oher _____________________________   Frequency:
Number of sexual partners in last 3 months?
Do you protect yourself from sexually transmitted infections (STIs)?	❏ No ❏ Yes, what method is used?
Do you use birth control?	❏ No ❏ Yes, what method is used?
Problems with sexual activity
Change in sex drive ❏	Infertility ❏	Exposure to sexually transmitted infections ❏	Females: Pain intercourse (dyspareunia) ❏	Females: Bleeding after intercourse (postcoital bleeding) ❏
Males: Inability to achieve erection (impotence) ❏	Males: Premature ejaculation ❏
Additional data:

 

Musculoskeletal System
Muscle twitching ❏	Muscle cramping/pain ❏	Muscle weakness ❏) ❏	Joint swelling (edema) or redness (erythema) ❏
Joint pain ❏	Joint stiffness/ deformity ❏	Noise with joint movement (crepitus) ❏	Limitations in range of motion ❏
Back pain ❏		Amount and kind of weekly exercise ❏	Osteoporosis screening ❏
Additional data:

 

 

Neurologic System
Headache ❏	Seizures ❏	Fainting/loss of consciousness (syncope) ❏	Changes in movement ❏
Inability to coordinate muscle movement (ataxia) ❏	Change in sensation ❏	Difficulty swallowing (dysphagia) ❏	Difficulty swallowing (dysphagia) ❏
		Use seat belts in a vehicle ❏	Wear helmet ❏
Additional data:

 

 

CLINICAL JUDGEMENT:

1. Recognize cues for this patient. Identify relevant and important data from the history. (Which information is relevant/irrelevant? Which information is most important? What is of immediate concern?)

 

1. Analyze cues. Organize and link the recognized cues to the patient’s clinical presentation. (Why is a particular cue or subset of cues of concern? What other information would help establish the significance of a cue or subset of cues?)

 

 

1. Using the analysis above, develop a problem list for this patient.