Ball: Seidels Guide to Physical Examination, 8th Edition

Chapter 01: The History and Interviewing Process

Student Checklist

Health History Guide Assessed

Appropriately
by Student?
Yes No Comments
I. Beginning data
A. Date and time
B. Source of data (patient, family member, etc.)
C. Name of interviewer and role (i.e., student
nurse)
II. Patients identifying information and biographic
data (cultural background, family structure,
education, and economic and environmental data
may be listed in the personal and social history
section.)
A. Name
B. Gender
C. Age
D. Birth date and place
E. Race and culture
F. Religion
G. Education
H. Marital status
I. Occupation
J. Address and phone number
K. Socioeconomic data (income, members of
household, means of transportation, etc.)
L. Other (source of referral, previous health care
provider)
III. Present illness
A. Chief concern (CC)
B. Symptoms (nature, course, location, and pattern
of problem)

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 Student Checklist 1-2

1. Date and timing (gradual or sudden onset,

duration, frequency)
2. Character, quality, quantity, and location
(generalized or radiating pain)
3. Associated events (setting)
4. Treatments (remissions)
5. Effect on other systems (appetite)
6. Influence on usual activities (sleep)
7. Other (coping ability)
IV. Medical history
A. Overall health before the presenting problem
B. Previous hospitalizations and illnesses/dates
1. Surgeries/dates
2. Serious injuries and disabilities/dates
3. Major childhood illnesses/dates
4. Major adult illnesses/dates
5. Other pertinent data
C. Previous health care
1. Recent health examination (physical, Pap smear,
x-rays, TB test, dental, vision, hearing)
2. Immunizations (polio, diphtheria, tetanus,
hepatitis B, influenza, mumps, rubella, pertussis,
pneumovax, measles, varicella)
3. Skin tests (BCG/PPD)
4. Other (obstetric care, screening tests, laboratory
work)
D. Current health/risk factors
1. Exercise (how often, duration)
2. Smoking (how much per day)
3. Alcohol (how often, amount, type)
4. Nutrition (caffeine, salt intake, amount)
5. Sleep pattern (number of hours /night)
6. Other (work stress, anxiety)
E. Medication data
1. OTC drugs (including vitamins)

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 Student Checklist 1-3

2. Prescriptions (dosage, schedule, including birth

control pills)
3. Allergies (transfusions, seasonal or
environmental, food, dyes)
4. Other (illegal drug use)
V. Family history
A. Status of family members
1. Family tree (narrative, genogram, pedigree)
2. Major health conditions (heart disease, high
blood pressure, cancer, tuberculosis, stroke, sickle
cell disease, cystic fibrosis, epilepsy, diabetes,
gout, kidney disease, thyroid disease, asthma or
other allergic condition, forms of arthritis, blood
diseases, sexually transmitted infections, familial
hearing, and visual or other sensory problems)
3. Genetic disorders (sickle cell disease)
VI. Personal and social history
If not addressed previously or if more information
is needed, describe cultural background, family
structure, stress factors, educational data,
economic status, and environmental data (home,
school, work, typical day)
VII. Review of physiologic systems
A. General, overall trends
1. Vital signs (temperature, pulse [apical and
radial], blood pressure, and respirations)
2. Previous measurements (height and weight;
head, chest, limb circumferences)
3. Usual health status (fatigue or fever patterns)
4. Other (recent change in usual condition)
B. Nutritional status
1. Usual diet (hour-by-hour diary)
2. Appetite trends
3. Food choices (preference foods)
C. Skin, hair, and nails
1. Usual condition of skin, hair, and nails
2. Previous diseases or problems (rash or eruption,
itching, pigmentation or texture change, excessive
sweating, abnormal nail or hair growth)

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 Student Checklist 1-4

3. New or recurrent conditions

D. Lymphatic system
1. Usual condition of lymphatic system (i.e.,
presence of lymphedema)
2. Previous lumps or nodules (neck or groin area
associated with an infection)
3. Other (lymph node enlargement, tenderness,
suppuration)
E. Head and neck
1. Usual condition of head and neck
2. Previous diseases or problems (headaches,
dizziness, syncope, trauma)
3. New or recurrent conditions
F. Eyes
1. Usual condition of eyes, any discharge
2. Previous diseases, problems (glaucoma or
trauma)
3. New or recurrent conditions
G. Ears, nose, and throat
1. Usual condition of ears, nose, and throat
2. Previous diseases, problems (tinnitus, vertigo,
infections, or surgeries)
3. New or recurrent conditions (nasal polyps,
hearing loss)
4. Other (associated allergies, condition of mouth
and teeth)
H. Chest and lungs
1. Usual condition of respiratory system
2. Previous disease or problems (cough, shortness
of breath, infections)
3. New or recurrent conditions (pain related to
respiration)
4. Other (last chest x-ray)
I. Heart and blood vessels
1. Usual condition of cardiovascular system
2. Previous diseases and problems (chest pain or
distress, palpitations, dyspnea, edema,
hypertension, previous myocardial infarction)

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 Student Checklist 1-5

3. New or recurrent conditions (chest pain,

orthopnea)
4. Other (last ECG)
J. Breasts
1. Usual condition of breasts
2. Previous diseases, problems (pain, tenderness,
discharge, lumps, galactorrhea)
3. New or recurrent conditions (tenderness, new
lump or nodule)
4. Other (last mammogram/date, breast self-
awareness, breast self-examination)
K. Gastrointestinal
1. Usual condition of alimentary tract (appetite,
digestion)
2. Previous diseases or problems (ulcers,
dysphagia, heartburn, nausea, vomiting,
hematemesis, flatulence, constipation, diarrhea,
hemorrhoids, jaundice, gallstones, polyps, tumor)
3. New or recurrent conditions (abdominal pain,
change in stool color or contents)
4. Other (previous diagnostic imaging)
L. Genitourinary (female)
1. Usual condition of genitourinary system
(including menstruation)
2. Previous diseases or problems (lesions, sexually
transmitted diseases, pain, discharges)
3. New or recurrent conditions (irregular menses)
4. Other (sexual and childbearing history)
M. Genitourinary (male)
1. Usual condition of genitalia (erections and
ejaculation data)
2. Previous diseases or problems (infertility)
N. Endocrine
1. Usual condition of endocrine system
2. Previous diseases or problems (diabetes)
3. New or recurrent conditions (thyroid
enlargement or tenderness, heat or cold
intolerance, unexplained weight change,
polydipsia, polyuria, changes in facial or body
hair, skin striae)

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 Student Checklist 1-6

4. Other (changes in facial or body hair, increased

hat and glove size)
O. Musculoskeletal system
1. Usual condition of musculoskeletal system
(gait)
2. Previous diseases or problems (joint stiffness,
restriction of motion)
3. New or recurrent conditions (pain, swelling,
redness, heat)
4. Other (deformities; limitations; use of devices,
e.g., canes, walkers)
P. Neurologic system
1. Usual condition of central nervous system
2. Previous diseases or problems (seizures,
tremors, tingling sensations)
3. New or recurrent conditions (loss of memory,
weakness or paralysis)
4. Other (previous motor, sensory, and cognitive
test results)
Q. Physiologic symptoms
1. Usual mental and psychologic abilities
2. Previous diseases or problems
3. New or recurrent conditions
4. Other (symptoms of Alzheimer disease)
R. Cross-system data
1. Data that depict endocrine changes (symptoms
that may suggest thyroid disease or diabetes)
NOTE: This outline can be used as a guide for recording findings related to a patients
age and condition.
Add data that are pertinent to the patient and omit the parts of the outline that are not
applicable.

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