HEALTH HISTORY
DO NOT ALTER THIS FORM
Patient must be 35 years or older
Must follow HIPPA guidelines
Interview must be completed in person
BIOGRAPHIC DATA (2 points)
Name (Initials): Age: Gender: Marital Status:
Date of Birth: Birthplace:
Address (City/State only)
Race:
Religion/Culture: None is NOT an answer!
Occupation:
Insurance Coverage: Only need to know if they have health insurance – do not need policy name or number
Source of Information AND Reliability: ex: Patient and appears to be reliable
PRESENT HEALTH OR ILLNESS
Reason for Seeking Care: (“In quotes”) (2 points)
“I am helping (insert your name here) with their school project”
Present Health: (chronological account of one priority health issue) (3 points)
(This section will be how you address the ANALYSIS OF DATA on page 6)
Do this section last!
Chronological account – give a thorough history (like an OLDCART)
PAST HISTORY (10 points) Childhood Diseases (age; measles, mumps, rubella, chickenpox, pertussis, strep throat, rheumatic fever, scarlet fever, poliomyelitis)
Ex: Measles early childhood (or their age, if they remember)
Denies all other diseases listed
Immunization Dates (influenza, pneumococcal, shingles; date of last tetanus; and date and results of last TB test)
If patient cannot recall the date, they can just provide an approximate date/age. For example: Patient states that they received their TB test within the last 5 years but cannot recall the exact date. Patient states that it was negative.
Accidents or Injuries (year; auto accidents, fractures, penetrating wounds, head trauma-especially if associated with unconsciousness, burns; complications)
Serious or Chronic Illnesses (asthma, depression, diabetes, hypertension, heart disease, HIV infection, hepatitis, sickle-cell anemia, cancer, seizure disorder; year of diagnosis)
Hospitalizations (year; cause, name of hospital, doctor, how the condition was treated, how long the person recovered)
Surgeries (year; type of surgery, date, name of surgeon, name of hospital, how person recovered)
If Surgery required an overnight stay in the hospital, then copy this in the hospital section as well. If the surgery was done as an outpatient procedure, then state that here only.
Last Examination Date (physical, dental, vision, hearing, ECG, chest x-ray, mammogram, colonoscopy, serum cholesterol)
Allergies (allergan and reaction)
(This can be food, medication and/or seasonal allergies)
Current Medications (prescription and OTC; name, dose, schedule)
FAMILY HISTORY (coronary artery disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast/ovarian cancer, colon cancer, sickle-cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, TB) (6 points)
List all family members here, along with whatever diseases they have. Then state that they deny all other diseases listed (for those diseases not in the family history).
This information should be what you transfer onto your Genogram.
Mother; HTN
Father DM
Paternal GPa COD: stroke; history of CAD
Denies all other diseases listed.
Genogram (3 generations to include parents and grandparents) – May complete on a separate page
REVIEW OF SYSTEMS (30 points)
Instructions: Highlight the symptom if present, then complete analysis for each symptom using OLDCART: (O = Onset, L = Location, D = Duration, C = Characteristics, A = Aggravating Factors, R = Relieving Factors, T = Treatment). EACH SYSTEM MUST BE ADDRESSED.
General Overall Health Status: Weight gain or loss, fatigue weakness or malaise, fever, chills, sweats or night sweats.
Example:
Skin: History of skin disease (eczema, psoriasis, hives), pigment or color change, change in a mole, excessive dryness or moisture, pruritus, excessive bruising, rash, or lesion.
Patient has noticed a recent change in a mole, but denies all other diseases listed:
O: Started 3 weeks ago
L: on their right shoulder
D: It has been consistently growing larger, with occasional bleeding.
C: Experiences tenderness when applying any pressure to the site.
A: Nothing that appears to aggravate this condition
R: Nothing appears to relieve this condition.
T: Has not used any medications on this site.
Health Promotion: Amount of sun exposure; method of self-care for skin.
Patient states that they get an average of 8-10 hours in the sun during the Summer, during life-guarding season. Patient states that they apply sunscreen at the beginning of the day but will occasionally not take time to re-apply sunscreen later in the day. Patient states that they shower once/day and applies lotion after bathing.
Hair: Recent loss, change in texture. Nails: change in shape, color, or brittleness.
Health Promotion: Method of self-care for hair and nails.
Head: Any unusual frequent or severe headache, any head injury, dizziness (syncope) or vertigo.
Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts.
Health Promotion: Wears glasses or contacts; last vision check or glaucoma test; and how coping with loss of vision if any.
Ears: Earaches, infections, discharge and its characteristics, tinnitus or vertigo.
Health Promotion: Hearing loss, hearing aid use, how loss affects the daily life, any exposure to environmental noise, and method of cleaning ears.
Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell.
Mouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste.
Health Promotion: Pattern of daily dental care, use of dentures, bridge, and last dental checkup.
Neck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter.
Respiratory System: History of lung diseases (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure.
Health Promotion: Last chest x-ray study, TB skin test.
Cardiovascular System: Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion [e.g., walking one flight of stairs, walking from chair to bath, or just talking]), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia.
Health Promotion: Date of last ECG or other heart tests, cholesterol screening.
Hematologic System: Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling.
Endocrine System: history of thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, diabetes, abnormal hair distribution.
FUNCTIONAL ASSESSMENT (Including Activities of Daily Living) (15 points)
Self-Esteem/Self-Concept: Education (last grade completed, other significant training), financial status (income adequate for lifestyle and/or health concerns), value-belief system (religious practices and perception of personal strengths).
Activity/Exercise: Note ability to perform ADLs: independent or needs assistance with feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, or climbing stairs. Any use of wheelchair, prostheses, or mobility aids?
Record leisure activities enjoyed and the exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring the body’s response to exercise).
Sleep/Rest: Sleep patterns, daytime naps, any sleep aids used.
Interpersonal Relationships/Resources: Social roles: “How would you say you get along with family, friends, and co-workers?”
Spiritual Resources: Faith : “Does religious faith or spirituality play an important part in your life? Yes/No Do you consider yourself to be a religious or spiritual person?” Yes/No Influence : “How does your religious faith or spirituality influence the way you think about your health or the way you care for yourself?” Their answer here. Community : “Are you a part of any religious or spiritual community or congregation?” Yes/No Address : “Would you like me to address any religious or spiritual issues or concerns with you?” Their answer here.
Coping and Stress Management: Kinds of stresses if life, especially in the past year, any change in lifestyle or any current stress, methods tried to relieve stress, and whether these have been helpful.
Personal Habits: Tobacco, “Do you smoke cigarettes (pipe, use chewing tobacco)?” “At what age did you start?” “How many packs do you smoke per day?” “How many years have you smoked?” Record the number of packs smoked per day (PPD) and duration (e.g., 1 PPD x 5 years). Then ask, “Have you ever tried to quit?” and “How did it go?” to introduce plans about smoking cessation.
Alcohol: Ask whether the person drinks alcohol. If yes, ask specific questions about the amount and frequency of alcohol use: “When was your last drink of alcohol?” “How much did you drink that time?” “Out of the past 30 days, about how many days would you say that you drank alcohol?” “Has anyone ever said you had a drinking problem?” If the person answers “no” to drinking alcohol, ask the reason for his decision (psychosocial, legal, health). Any history of alcohol treatment? Involvement in recovery activities? History of family member with problem drinking?
Illicit or Street Drugs: Ask specifically about marijuana, cocaine, crack cocaine, amphetamines, heroin, pain killers like OxyContin or Vicodin, and barbiturates. Indicate frequency of use and how usage has affected work or family.
Environment/Occupational Hazards: Housing and neighborhood (living alone, knowledge of neighbors), safety of area, adequate heat and utilities, access to transportation, and involvement in community services. Note environmental health, including hazards in workplace (asbestos, inhalants, chemicals, or repetitive motion). Wear any protective equipment? Aware of any health problems now that may be related to work exposure? Geographic exposures including travel or residence in other countries, including time spent abroad during military service.
ANALYSIS OF DATA (8 points)
Review the collected subjective data and identify the PRIORTY body system for the client and state the rationale for selecting the system.
This section is directly related to you identified priority health issue that you identified on page 1 (Present Health: (chronological account of one priority health issue))
· Priority System:
· Rationale for Selecting this System:
List two (2) Teaching/Learning needs related to the PRIORITY system listed above.
1.
2.
REFLECTION (20 points and 4 points for APA) – Separate Document (2-3 pages, APA format – 7th edition – please refer to your resources for additional APA guidelines.)
First, reflect on your interaction with the interviewee holistically. Consider the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process (if needed, refer to your text for a description of therapeutic communication and of the interview process). Finally, be sure your reflection addresses EACH of these questions:
Address these in the order that they are written here – you can use a paragraph (or more) for each of these questions in your paper.
REMEMBER TO MAINTAIN HIPPA
· How did you prepare yourself and the patient for the interview?
· Describe the environment in which the interview took place.
· Describe the therapeutic communication techniques utilized during the interview.
· What barriers to communication did you experience? How did you overcome them? What will you do to overcome them in the future?
· Were there unanticipated challenges to the interview?
· What went well?
· Was there information you wished you had obtained?
· How will you alter your approach next time?
Include a reference page with textbook citation.
