Types of health histories
an assessment for a new patient
What is a comprehensive health assessment?
7 components of comprehensive health history
what is
1. identifying data
2. chief complaints
3. history of present illness
4. past history
5. family history
6. review of systems
7. health patterns
DPT, polio
MMR, varicella
HepA, HepB
Hib, HPV
Tdap, TD
Meningococcal, pneumococcal
Shingles, Covid
Flu vaccine
What are immunizations?
Average day (routines, habits, activities, function)
Self-perception - self-concept
Values – beliefs
Activity – exercise
Sleep – rest
Nutrition –hydration
Role – relationship
Coping – stress tolerance, relaxation, recreation
What are examples of health?
Hospitalizations, medical illnesses, accidents, psychiatric hospitalizations, surgical history, blood transfusion history, obstetric
What are adult illnesses, injuries, and surgeries?
Returning patient, routine or urgent-care visits
What is a focused or problem-oriented assessment?
Type of reaction
What are medications/allergies?
TB
Cholesterol
Colorectal cancer screening
Mammogram
Pap smear
Bone density
Eye exam/retinal exam
What are screening tests?
Weight gain
Caloric intake exceeds caloric expenditure over time
Reduced body metabolism
Abnormal accumulation of body fluids
Weight loss
Important symptom with many causes
GI, endocrine, chronic infections, cancer, chronic cardiac, pulmonary, or renal failure, depression, eating disorders
Poor food choices, inability to cook or poor cooking habits, inability to access food stores, or lack of finances
What is nutritional status and overall health?
Number of pregnancies
What is gravida?
Evaluate whether treatment was effective; update status of concerns/symptoms
What is a follow-up history?
Patient is usually the source
Other sources:
- family, proxy
- medical record
If question about reliability of information, state reason
What is the source/reliability of information?
Bicycle helmet, sports protective gear
Seat belts
Smoke, CO & radon detectors
Firearms
Sun protection
Childproof caps
Fall hazards, grab bars
Burns
Poisons
What are safety and health risks?
What is a review of systems?
Measles
Mumps
Rubella
Chicken pox
Scarlet fever
Measles
Mumps
Rubella
Chicken pox
Scarlet fever
What is childhood illnesses?
Focused or emergent problem
Airway, breathing, circulation, or other rapid assessment
What is emergency history?
•physical, mental, social, emotional, spiritual and behavioral health
What is providing fundamental and personalized knowledge?
Describe current and previous jobs including short-term or seasonal and military service
Describe home location (consider air quality, drinking water supply, tick exposure, environmental risks)
Recreational exposures
Travel history
What are environmental health and risks/exposures?
mental health or sexual history
Family violence
What are sensitive topics?
What is the number of viable births
(twins are only ONE birth)
What is para?
Use person's own words
May have more than one reason for seeking care at this time
DOB, Birthplace
Marital/relationship status
Educational background
Living situation
Occupation
Primary language (spoken, reading)
Tobacco, alcohol, recreational drugs, caffeinated beverages
What are substances?
Shared ideas, rules, and meanings that influence how we view the world, experience it emotionally, and spiritual practices
What is culture?
Military service is associated with:
•stressors,
•toxic exposures,
•hazards, and
•safety risks not commonly encountered in the civilian population.
What is the military history?