The Complete Health History

Flashcard maker : Candace Young
Sequence of Health History
1. Biographic data
2. Reason for seeking care
3. Present health or history of present illness
4. Past history
5. Family history
6. Review of systems
7. Functional assessment or activities of daily living (ADLs)
What outdated term did \”Reason for seeking care\” replace?
Chief Complaint (CC)
Eight critical characteristics of History of Present Illness
1. Location
2. Character or Quality
3. Quantity or Severity
4. Timing
5. Setting
6. Aggravating or Relieving Factors
7. Associated Factors
8. Patient’s Perception
Noting timing of symptoms includes:
1. Onset (Exactly when did it first occur?)
2. Duration (How long did it last?)
3. Frequency (How often does it occur?)
PTA
prior to arrival
HHx
Health History
sequelae
Pathological conditions resulting from a previous disease (e.g., rheumatic fever, scarlet fever, poliomyelitis).
Past Health
1. Childhood Illnesses
2. Accidents or Injuries
3. Serious or Chronic Illnesses
4. Hospitalizations
5. Operations
6. Obstetric History
7. Immunizations
8. Last Examination Date
9. Allergies
10. Current Medications
HHx – Hospitalizations
1. Cause
2. Name of hospital
3. How the condition was treated
4. Duration
5. Name of physician
HHx – Operations
1. Type of surgery
2. Date
3. Name of surgeon
4. Name of hospital
5. How the person recovered
HHx – Obstetric
1. Gravidity (pregnancies): Grav #
2. Full term deliveries (term): Term #
3. Preterm pregnancies (preterm): Preterm #
4. Incomplete pregnancies (abortions): Ab #
Spontaneous (S) #; Induced (I) #
5. Children living (living): Living #
pedigree or genogram
A graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations, such as parents, grandparents, siblings.
syncope
dizziness
acuity
sharpness; clarity; severity (as of pain)
diplopia
double vision
dysphagia
difficulty swallowing
dyspnea
shortness of breath
nocturia (also called nycturia)
excessive urination at night
claudication
limping, frequently due to insufficient blood flow to the leg muscles
thrombophlebitis
inflammation of a vein resulting in a thrombus
thrombus
blood clot in a vein that remains where it formed
pyrosis
esophageal and stomach burning sensation with sour eructation
fistula
an abnormal duct or passageway leading from an organ to the body surface, or to another organ, usually resulting from an injury or disease
dyspareunia
pain during sexual intercourse
polydipsia
constant excessive thirst
polyphagia
excessive appetite or eating
ADLs (examples)
1. bathing
2. dressing
3. toileting
4. eating
5. walking
IADLs
Instrumental activities of daily living (those needed for independent living)
IADLs (examples)
1. housekeeping
2. shopping
3. cooking
4. doing laundry
5. using the telephone
6. managing finances
7. nutrition
8. social relationships and resources
9. self-concept and coping
10. home environment
FICA
faith, influence, community, address
FICA (what is it used for?)
To incorporate a person’s spiritual values into the health history.
CAGE
1. Cut down
2. Annoyed
3. Guilty
4. Eye opener
hydrocele
a fluid-filled cavity or duct, especially in the scrotum
Adolescent HHx
HEEADSSS
HEEADSSS
Home environment
Education & Employment
Eating
peer-related Activities
Drugs
Sexuality
Suicide/depression
Safety

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