Components of Nursing Health History

BIOGRAPHIC DATA

Includes client’s name, address, age, sex, marital status, occupation, religious preference,
health care financing, and usual source of medical care.

CHIEF COMPLAINT OR REASON FOR VISIT

The client’s answer to the question “What brought you to the hospital?” or “What is
troubling you?” is expressed in the client’s own words

HISTORY OF PRESENT ILLNESS

This includes the onset of symptoms, when the symptoms started, if its development was
sudden or gradual, severity and frequency of occurrence, the site or exact location of
distress; the character of the complaint, its intensity or quality of discharge, sputum, etc.;
activity of the client which may be involved in the development of the problem,
phenomena or symptoms associated with the chief complaint, and the factors that
aggravate or alleviate the problem.

PAST HISTORY

This includes childhood illnesses, immunizations, allergies to drugs, animals, or other

environmental agents, accidents and injuries, hospitalizations for serious illnesses, and
medications currently used.

FAMILY HISTORY OF ILLNESS

This is to ascertain risk factors for diseases. Particular attention should be given to
disorders such as diseases of the heart, tuberculosis, cancer, diabetes, hypertension,
obesity, allergies, arthritis, bleeding, alcoholism, and any mental disorders.

LIFESTYLE

This includes personal habits, diet, sleep/ rest patterns, activities of daily living,
instrumental activities of daily living, recreation or hobbies.

SOCIAL DATA

This pertains to quality of family relationships/friendships, ethnic affiliation, educational

background, occupational history, economic status, home and neighborhood conditions.

PSYCHOLOGICAL DATA
These are major stressors experienced by the client and their perception of them, how
they cope up with these stressors, their communication to relay appropriate emotion.

PATTERNS OF HEALTH CARE

Includes all the health care resources that the client is currently using and has used in the
past.

Review of Systems
The following list illustrates the content of a complete review of systems.

General/Constitutional
Average weight, weight loss or gain, general state of health, sense of well-being,
strength, ability to conduct usual activities, exercise tolerance
Skin/Breast
Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth
or loss, nail changes
Breast lumps, tenderness, swelling, nipple discharge
Eyes/Ears/Nose/Mouth/Throat
Headaches (location, time of onset, duration, precipitating factors), vertigo,
lightheadedness, injury
Vision, double vision, tearing, blind spots, pain
Nose bleeding, colds, obstruction, discharge
Dental difficulties, gingival bleeding, dentures
Neck stiffness, pain, tenderness, masses in thyroid or other areas
Cardiovascular
Precordial pain, substernal distress, palpitations, syncope, dyspnea on exertion,
orthopnea, nocturnal paroxysmal dyspnea, edema, cyanosis, hypertension, heart
murmurs, varicosities, phlebitis, claudication
Respiratory
Pain (location, quality, relation to respiration), shortness of breath, wheezing,
stridor, cough (time of day, of productive, amount in tablespoons or cups per day
and color of sputum), hemoptysis, respiratory infections, tuberculosis (or
exposure to tuberculosis), fever or night sweats
Gastrointestinal
Appetite, dysphagia, indigestion, food idiosyncrasy, abdominal pain, heartburn,
eructation, nausea, vomiting, hematemesis, jaundice, constipation, or diarrhea,
abnormal stools (clay-colored, tarry, bloody, greasy, foul smelling), flatulence,
hemorrhoids, recent changes in bowel habits
Genitourinary
Urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or
change in) color of urine, stones, infections, nephritis, hesitancy, change in size of
 stream, dribbling, acute retention or incontinence, libido, potency, genital stores,
discharge, venereal disease
(Female) Age of onset of menses, regularity, last period, dysmenorrhea,
menorrhagia, or metrorrhagia, vaginal discharge, post-menopausal bleeding,
dyspareunia, number and results of pregnancies (gravida, para)
Musculoskeletal
Pain, swelling, redness or heat of muscles or joints, l;imitation, of motion,
muscular weakness, atrophy, cramps
Neurologic/Psychiatric
Convulsions, paralyses, tremor, incoordination, parathesias, difficulties with
memory of speech, sensory or motor disturbances, or muscular coordination
(ataxia, tremor)
Predominant mood "nervousness" (define), emotional problems, anxiety,
depression, previous psychiatric care, unusual perceptions, hallucinations
Allergic/Immunologic/Lymphatic/Endocrine
Reactions to drugs, food, insects, skin rashs, trouble breathing
Anemia, bleeding tendency, previous transfusions and reactions, Rh
incompatibility
Local or general lymph node enlargement or tenderness. -Polydipsia, polyuria,
asthenia, hormone therapy, growth, secondary sexual development, intolerance to
heat or cold

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