Health History Taking
General Approach to Health History Taking
Present with a professional appearance
Ensure an appropriate environment
Sit facing the patient at eye level
Ensure that the patient is comfortable as possible
Ask the patient whether there are any questions about the
interview before it is started
THE HEALTH HISTORY: Purpose
Data collection
Initiate and maintain a helping relationship. (rapport, trust, care, and
concern)
Indication of nursing diagnosis
Identify special concerns and perceptions
Demographic and social information
THE HEALTH HISTORY: STRUCTURE
Subjective Data
What the patient tells you: The history, from chief complaint through
Review of Systems.
Example:
Mrs. G is a 54-year-old hairdresser who reports pressure over her left
chest “like an elephant sitting there,” which goes into her left neck and
arm.
Objective Data
What you detect on the examination: All physical examination findings.
Example:
Mrs. G is an older white female, deconditioned, pleasant, and
cooperative.
BP 160/80, HR 96 and regular, respiratory rate 24, afebrile.
THE HEALTH HISTORY: Components
Identifying Data
Reliability
Chief Complaint(s)
Present Illness
Past History
Family History
Personal and Social History
Review of Systems
■ Identifying data—such as age, gender, occupation, marital status
■ Source of the history—usually the patient, but can be family member, friend
and the medical record .
■ If appropriate, establish source of referral, since a written report may be
needed.
Reliability
Varies according to the patient’s memory, trust, and mood
Chief Complaint(s)
The one or more symptoms or concerns causing the patient to seek care
Present Illness
■ Amplify the Chief Complaint, describes how each symptom developed
■ Includes patient’s thoughts and feelings about the illness
■ Pulls in relevant portions of the Review of Systems (see below)
■ May include medications, allergies, habits of smoking and alcohol, since these
are frequently pertinent to the present illness
Seven attributes Of Chief Complaint(s).
(1) Location Where is it? Does it radiate?
(2) Quality. What is it like?
(3) Quantity or severity . How bad is it? (For pain, ask for a rating on a scale of 1
to 10.)
(4) Timing, including onset, duration, and frequency, When did (does) it start?,
How long did (does) it last?, How often did (does) it come?
(5) The setting in which they occur
Include environmental factors, personal activities, emotional reactions, or other
circumstances that may have contributed to the illness
(6) Factors that have aggravated or relieved the symptoms, Does anything
make it better or worse?
(7) Associated Manifestations.
Have you noticed anything else that accompanies it?
Past History
■ Lists childhood illnesses
■ Lists adult illnesses with dates for at least four categories: medical; surgical;
obstetric/ gynecologic; and psychiatric
■ Includes health maintenance practices such as: immunizations, screening
tests, lifestyle issues, and home safety
■ Outlines or diagrams of age and health, or age and cause of death of siblings,
parents, and grandparents
■ Documents presence or absence of specific illnesses in family, such as
hypertension, coronary artery disease, etc. Describes educational level, family
of origin, current household, personal interests and lifestyle .
Family History
■ Outlines or diagrams of age and health, or age and cause of death of siblings,
parents, and grandparents
■ Documents presence or absence of specific illnesses in family, such as
hypertension, coronary artery disease, etc.
Personal and Social History
Describes educational level, family of origin, current household, personal
interests and lifestyle.
Review of Systems
Documents presence or absence of common symptoms related to each major
body system.
Review of Systems:
General
Has gained about 10 lb in the past 4 years, Skin, No rashes or other changes.
Head, Eyes, Ears, Nose, Throat (HEENT).
Eyes:
Reading glasses for 5 years.
Ears:
Hearing good, No tinnitus, vertigo and infections.
Nose sinuses:
Occasional mild cold.
Throat (mouth and pharynx):
Some bleeding of gums recently. Last dental visit 2 years ago.
Neck
No lumps, goiter, pain, No swollen glands.
Breasts
No lumps, pain, discharge. Does self-breast exam sporadically.
Respiratory
No cough, wheezing, shortness of breath and Last chest x-ray unremarkable.
Cardiovascular
No known heart disease or high blood pressure; No dyspnea, orthopnea, chest
pain, palpitations. Has never had an electrocardiogram (ECG).
Gastrointestinal
Appetite good; no nausea, vomiting, indigestion. Bowel movement about once
daily, no diarrhea or bleeding, No pain, jaundice, gallbladder or liver problems.
Urinary
No frequency, dysuria, hematuria, or recent flank pain; nocturia × 1, large
volume and Occasionally loses some urine when coughs hard.
Genital
Male: Hernias, discharge from or sores on the penis
Female: H/o vaginal discharge, No Hx of Gnorrhoea, Syphillus
Peripheral Vascular
Intermittent claudication, leg cramps, varicose veins, past clots in the veins.
Musculoskeletal
Muscle or joint pains, stiffness, arthritis, gout, and backache.
Neurologic
Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation
Nervous System.
Mental Status
Assess the patient’s orientation, mood, thought process, thought content,
Cranial Nerves.
Facial movements, gag reflex
Motor System
Muscle bulk, tone, and strength of major muscle groups. Point-to-point
movements, such as finger-to-nose (F → N)
Sensory System
Pain, temperature, light touch, vibration, and discrimination.
Hematologic
Anaemia, easy bruising or bleeding, past transfusions and/or transfusion
reactions.
Endocrine
Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or
hunger, polyuria, change in glove or shoe size.
Psychiatric
Nervousness, tension, mood swings, including depression
