Nursing Health History
is used to identify patterns of health and illness, risk factors for
physical and behavioral health problems, deviation from normal, and to help find
Guidelines for Conducting Heath Assessment
Encourage honest communication
Make eye contact
Be aware of your own non verbal communication
Avoid technical terms
Consider educational and cultural background and any disabilities that the patient may
Components of the Health History
identifies the client and may include:
Name, age, sex, race, marital status, social security number, education,
occupation, religion, closest relative, physician, and medical record number
a short statement recorded in the patient’s own words and in
quotation marks (“I have not been able to breath for about 2 weeks)
Present Health Concern/Illness
the single most important factor that the health team
needs to diagnose or determine the client’s needs.
The physical examination only
validates the information obtained.
Diagnostic test often support, rather than establish
Gather relevant and essential data about the onset and duration of symptoms.
Record information about the location, intensity, and quality of symptoms.
Find out what
actions precipitate the symptoms, makes them worse, or provides relief
assess whether the client has ever been hospitalized, or has had surgery,
description of allergies (if present, not specific reaction and treatment), identify habits
and lifestyles, alcohol, tobacco, caffeine, OTC drugs or routinely taken meds, assess
patterns of sleep, exercise and nutrition, check general health and immunization status,
last physical exam CXR, EKG, eye exam, dental checkup, pap smear and mammogram,
testicular and digital rectal exams, previous illnesses are discussed
the age, health status, or the age and cause of death of relative are
obtained to identify genetic, communicable, or environmental diseases.
First order r
elatives and second order relatives, diseases such as hypertension, heart disease, diabetes,
epilepsy, mental illness, TB, kidney disease, arthritis, allergies, asthma, alcoholism and
A genogram or family tree is an easy way to record such data