COMPREHENSIVE HEALTH HISTORY

STUDENT NURSE: __________________________________ GROUP: _____ DUTY SCHEDULE: ____________________

AREA: _____________________

BIOGRAPHIC DATA • ALLERGIES

CLIENT’S NAME: _____ Foods

ADDRESS: _____ Drugs

AGE: _____ Insects

SEX: _____ Environmental Agents

MARITAL STATUS: Others (specify):

OCCUPATION:

RELIGION: Reactions:

HEALTH CARE FINANCING: Treatment:

USUAL SOURCE OF MEDICAL CARE: • ACCIDENTS AND INJURIES

How:

CHIEF COMPLAINT OR REASON FOR VISIT When:

Where:

Type of injury:

HISTORY OF PRESENT ILLNESS Treatment received:

ONSET OF SYMPTOMS: Complications:

WAS THE ONSET SUDDEN OR GRADUAL? • HOSPITALIZATION FOR SERIOUS ILLNESSES

HOW OFTEN DOES IT OCCUR? Reason:

EXACT LOCATION OF DISTRESS: Date:

CHARACTER OF COMPLAINT (INTENSITY OR QUALITY): Surgery performed:

Course of recovery:

ACTIVITY WHEN IT OCCURRED: Complications:

SYMPTOMS ASSOCIATED WITH THE CHIEF COMPLAINT: • MEDICATIONS (currently used or prescribed)

ALLEVIATING FACTORS: FAMILY HISTORY OF ILLNESSES

AGGRAVATING FACTORS: _____ Tuberculosis

_____Heart disease

PAST HISTORY _____ Diabetes

• CHILDHOOD ILLNESSES _____ Hypertension

_____ Chickenpox _____ Arthritis

_____ Mumps _____ Stroke

_____ Measles _____ Cancer

_____ Rubella (German measles) _____ Obesity

_____ Rubeola (Red measles) _____ Bleeding

_____ Streptococcal infections _____ Alcoholism

_____ Scarlet fever _____ Mental illness

_____ Rheumatic fever Others (specify):

Others (specify):

• CURRENT STATE OF HEALTH (with their respective

age)
• CHILDHOOD IMMUNIZATIONS
Grandfather:
_____ Complete
Grandmother:
_____ Incomplete
Father:
Date of last tetanus shot:
Mothers name:

Siblings:
 COMPREHENSIVE HEALTH HISTORY
STUDENT NURSE: __________________________________ GROUP: _____ DUTY SCHEDULE: ____________________
AREA: _____________________

Highest level of attainment:

Past difficulties with learning:

LIFESTYLE • OCCUPATIONAL HISTORY

• PERSONAL HABITS Current employment status:

Substance: Type of occupation:

Amount: Occupational hazards:

Frequency: Overall satisfaction with work:

Duration: • ECONOMIC STATUS

• DIET Payment of medical care:

Typical diet on a normal day: Does illness presents financial concerns?

Special diet: • HOME AND NEIGHBORHOOD CONDITIONS

Number of meals per day: Home safety measures and adjustments in regards with
the illness:
Number of snacks per day:

Person who cooks food:

Availability of community services that meet the needs:
Allergies:

• SLEEP/REST PATTERNS
PSYCHOLOGIC DATA
Usual number of hours of sleep:
MAJOR STRESSORS:
Usual waking time:

Usual sleeping time:

USUAL COPING PATTERN:
Difficulties in sleep/wake pattern:

Remedies during difficulties:

COMMUNICATION STYLE
• ACTIVITIES OF DAILY LIVING (ADLs)

_____ Able to perform ADLs well

PATTERNS OF HEALTH CARE
Difficulty in performing ADLs:
• HISTORY OF HEALH CARE RESOURCES USED:
_____ Eating
_____ Primary care provider
_____ Grooming
_____ Specialists
_____ Dressing
_____ Dentists
_____ Elimination
_____ Folk practitioners
_____ Locomotion
_____ Health clinic/center
• RECREATION/HOBBIES
• PERCEPTION OF HEALTH CARE PROVIDED:
Exercise activity:
_____ Adequate
Tolerance:
_____ Inadequate
Hobbies and other interests:

SOCIAL DATA

• FAMILY RELATIONSHIPS/FRIENDSHIPS

Support systems in times of stress:

Effect of family in illness:

Family problem affecting illness:

• ETHNIC AFFILIATION

Health customs and beliefs:

Cultural practices that affect health care and recovery:

• EDUCATIONAL HISTORY