HEALTH ASSESSMENT EXAM 1 NOTES
*** Chapter 4 – The Complete Health History ***
Subjective data—what the person says about himself or herself
Objective data—what you observe through measurement, inspection, palpation,
percussion, and auscultation
The Health History –The Adult
Record time & date of the interview
1. Biographic Data –includes name, address, phone number, age and birth date,
birthplace, gender, marital partner status, race, ethnic origin, and occupation.
Record the person’s primary language
Source of History
Record who furnishes the info—person him/herself is most reliable but may
be an interpreter or caseworker, relatives and friends are less reliable
Judge how reliable the informant seems
Note if the person seems well or ill
Sample statements: Patient herself, who seems reliable or Patients son, John
Ramirez, who seems reliable, etc.
2. Reason for Seeking Care
Brief, spontaneous statement in the persons own words that describes
reason for the visit
States one (maybe two) symptoms of signs & their duration
Symptom = subjective sensation that the person feels from the disorder
Sign= objective abnormality that you as the examiner could detect on a
physical examination or in lab reports
Record persons exact words and record a time frame
Sample statements: “Chest pain for 2 hours” or “Sore throat for 3 days now
and just getting worse”
3. Present Health or History of Present Illness
For healthy person – “I feel healthy right now”
For ill person—your final summary of any symptom the person has should
include these 8 characteristics:
1. Location—specific, ask person to point to the location. If pain is the
problem, note the precise site (ex. head pain is vague, whereas pain
behind the eyes or jaw pain is more precise. Is the pain localized to
this site or radiation? Is it superficial or deep?
2. Character or Quality—specific descriptive qualities (burning, sharp,
dull, aching, shooting, etc.) Use similes—ex. does blood in the stool
look like sticky tar?
3. Quantity or Severity—try to quantify the sign or symptom ex. profuse
menstrual flow soaking 5 pads/hr. With pain, avoid adjectives and ask
how it affects daily activities. Record if person says something like “I
was able to go to work but then I came home and went to bed” (Also
use Pain scale 1-10)
4. Timing—(onset, duration, frequency) when did the symptom first
appear? Report must include answers to Q’s such as:
, how long did the symptom last (duration)?
Was it steady (constant) or did it come and go during that time
(intermittent)?
Did it resolve completely and reappear days or weeks later (cycle
of remission and exacerbation)?
5. Setting—where was person or what were they doing when the
symptom started? What brings it on?
6. Aggravating or Relieving Factors—what makes pain worse? Is it
aggravated by weather, activity, food, medication, standing bent
over, fatigue, time of day, or season? What relieves it (rest,
medication, ice pack)? Ask what they have tried or what seems to
help?
7. Associated Factors—is primary symptom associated with any others
(ex. urinary frequency and burning associated w/ fever and chills)
8. Patients Perception—find out the meaning of the symptom by asking
how it affects daily activities
Organize question sequence into: PQRSTU
P Provocative or Palliative – what brings it on? What were you
doing during onset? What makes it better/worse?
Q Quality or Quantity – how does it look, feel, sound? How
intense/severe is it?
R Region or Radiation – Where is it? Does it spread?
S Severity Scale – How bad is it (on scale 1-10)? Getting
better, worse, staying the same?
T Timing – onset (when did it first occur), duration (how long
did it last), and frequency (how often does it occur)
U Understand Patient’s Perception of the problem (“what do
you think it means?”)
4. Past Health
Childhood illnesses
Accidents or Injuries
Serious or chronic illnesses
Hospitalizations
Operations
Obstetric history
Immunizations
Last examination date
Allergies
Current medications
5. Family History
Accurate family history can help with prevention (patient may seek early
screening and periodic surveillance)
Pedigree/genogram—graphic family tree
Review of Systems
General overall health state – weight (gain/loss over what period of time), fatigue,
weakness or malaise, fever, chills, sweats or night sweats
Skin—history of skin disease, pigment or color change, excessive dryness or
moisture, excessive bruising, rash, lesion
Hair—recent loss or change in texture (nails: change in shape, color, or brittleness)
, Head—unusually frequent or severe headache; head injury, dizziness or vertigo
Eyes—difficulty with vision, eye pain, redness or swelling, watering or discharge
Ears—earaches, infections, discharge, tinnitus, vertigo
Nose and sinuses—discharge and its char. Sinus pain, nosebleeds, change in sense
of smell
Mouth and throat—mouth pain, frequent sore throat, bleeding gums, toothache,
lesion in mouth or tongue, hoarseness or voice change, altered taste
Neck—pain, limited motion, lumps or swelling, enlarged or tender nodes, goiter
Breast—pain, lump, nipple discharge, history of breast disease, surgeries done
Axilla—tenderness, lump, swelling or rash
Respiratory system –history of lung disease, chest pain while breathing, wheezy or
noisy breathing, shortness of breath, cough, sputum
Cardiovascular—chest pain, pressure, tightness or fullness, palpitation, cyanosis,
dyspnea or exertion, etc. specify amount of exertion ex. walking one flight of stairs,
walking from chair to bath, or just talking
Peripheral vascular—coldness, numbness and tingling, swelling of legs (time of day
and activity), discoloration of hands or feet, varicose veins, ulcers
Gastrointestinal—appetite, heartburn, indigestion, pain (assoc. with eating), other
ab pain, nausea and vomiting, vomiting blood, black stools, rectal bleeding,
frequency of bowel movement, flatulence
Urinary system—frequency, urgency, nocturia (# of times person wakes up to pee
at night, recent change), dysuria, polyuria, UTI, kidney stones
Male genital system—penis or testicular pain, sores/lesions, penile discharge,
lumps, hernia
Female genital system—menstrual history, vaginal itching, discharge and char, age
at menopause, menopausal signs and symptoms, postmenopausal bleeding
Sexual health—“I usually ask all patients about their sexual health”—then: “are
you presently in a relationship involving intercourse?” contraceptives? STIs?
Musculoskeletal system—history of arthritis or gout. In joints: pain stiffness,
swelling (location, migratory nature, deformity, limitation of motion, noise with
joint motion? In muscles: pain, cramps, weakness, gait problems, coordination
problems? In the back: any pain, stiffness, limitation of motion, history of back pain
or disk disease?
Neurologic System—history of seizure disorder, stroke, fainting, blackouts. Motor
function: weakness, paralysis, coordination problems? Sensory function:
numbness, tingling? Cognitive function: memory disorder (recent or distant,
disorientation?), mental status: nervousness, mood change, depression,
hallucinations, etc
Hematologic System—bleeding tendency of skin or mucous membranes, excessive
bruising, lymph node swelling, blood transfusion and reactions
Endocrine system—history of diabetes or thyroid disease, excessive sweating,
relationship b/w weight and appetite, abnormal hair distribution, tremors,
nervousness, need for hormone therapy
Functional Assessment (including Activities of Daily Living)
Measures a person’s self-care abilities in the areas of general physical health or
absence of illness.
Self esteem/concept: education, financial status, value-belief system (religious)
Activity/exercise: a daily profile reflecting usual daily activities (note ability to
perform ADLs)
Sleep/rest: sleep patterns, day naps, any sleep aids used?
*** Chapter 4 – The Complete Health History ***
Subjective data—what the person says about himself or herself
Objective data—what you observe through measurement, inspection, palpation,
percussion, and auscultation
The Health History –The Adult
Record time & date of the interview
1. Biographic Data –includes name, address, phone number, age and birth date,
birthplace, gender, marital partner status, race, ethnic origin, and occupation.
Record the person’s primary language
Source of History
Record who furnishes the info—person him/herself is most reliable but may
be an interpreter or caseworker, relatives and friends are less reliable
Judge how reliable the informant seems
Note if the person seems well or ill
Sample statements: Patient herself, who seems reliable or Patients son, John
Ramirez, who seems reliable, etc.
2. Reason for Seeking Care
Brief, spontaneous statement in the persons own words that describes
reason for the visit
States one (maybe two) symptoms of signs & their duration
Symptom = subjective sensation that the person feels from the disorder
Sign= objective abnormality that you as the examiner could detect on a
physical examination or in lab reports
Record persons exact words and record a time frame
Sample statements: “Chest pain for 2 hours” or “Sore throat for 3 days now
and just getting worse”
3. Present Health or History of Present Illness
For healthy person – “I feel healthy right now”
For ill person—your final summary of any symptom the person has should
include these 8 characteristics:
1. Location—specific, ask person to point to the location. If pain is the
problem, note the precise site (ex. head pain is vague, whereas pain
behind the eyes or jaw pain is more precise. Is the pain localized to
this site or radiation? Is it superficial or deep?
2. Character or Quality—specific descriptive qualities (burning, sharp,
dull, aching, shooting, etc.) Use similes—ex. does blood in the stool
look like sticky tar?
3. Quantity or Severity—try to quantify the sign or symptom ex. profuse
menstrual flow soaking 5 pads/hr. With pain, avoid adjectives and ask
how it affects daily activities. Record if person says something like “I
was able to go to work but then I came home and went to bed” (Also
use Pain scale 1-10)
4. Timing—(onset, duration, frequency) when did the symptom first
appear? Report must include answers to Q’s such as:
, how long did the symptom last (duration)?
Was it steady (constant) or did it come and go during that time
(intermittent)?
Did it resolve completely and reappear days or weeks later (cycle
of remission and exacerbation)?
5. Setting—where was person or what were they doing when the
symptom started? What brings it on?
6. Aggravating or Relieving Factors—what makes pain worse? Is it
aggravated by weather, activity, food, medication, standing bent
over, fatigue, time of day, or season? What relieves it (rest,
medication, ice pack)? Ask what they have tried or what seems to
help?
7. Associated Factors—is primary symptom associated with any others
(ex. urinary frequency and burning associated w/ fever and chills)
8. Patients Perception—find out the meaning of the symptom by asking
how it affects daily activities
Organize question sequence into: PQRSTU
P Provocative or Palliative – what brings it on? What were you
doing during onset? What makes it better/worse?
Q Quality or Quantity – how does it look, feel, sound? How
intense/severe is it?
R Region or Radiation – Where is it? Does it spread?
S Severity Scale – How bad is it (on scale 1-10)? Getting
better, worse, staying the same?
T Timing – onset (when did it first occur), duration (how long
did it last), and frequency (how often does it occur)
U Understand Patient’s Perception of the problem (“what do
you think it means?”)
4. Past Health
Childhood illnesses
Accidents or Injuries
Serious or chronic illnesses
Hospitalizations
Operations
Obstetric history
Immunizations
Last examination date
Allergies
Current medications
5. Family History
Accurate family history can help with prevention (patient may seek early
screening and periodic surveillance)
Pedigree/genogram—graphic family tree
Review of Systems
General overall health state – weight (gain/loss over what period of time), fatigue,
weakness or malaise, fever, chills, sweats or night sweats
Skin—history of skin disease, pigment or color change, excessive dryness or
moisture, excessive bruising, rash, lesion
Hair—recent loss or change in texture (nails: change in shape, color, or brittleness)
, Head—unusually frequent or severe headache; head injury, dizziness or vertigo
Eyes—difficulty with vision, eye pain, redness or swelling, watering or discharge
Ears—earaches, infections, discharge, tinnitus, vertigo
Nose and sinuses—discharge and its char. Sinus pain, nosebleeds, change in sense
of smell
Mouth and throat—mouth pain, frequent sore throat, bleeding gums, toothache,
lesion in mouth or tongue, hoarseness or voice change, altered taste
Neck—pain, limited motion, lumps or swelling, enlarged or tender nodes, goiter
Breast—pain, lump, nipple discharge, history of breast disease, surgeries done
Axilla—tenderness, lump, swelling or rash
Respiratory system –history of lung disease, chest pain while breathing, wheezy or
noisy breathing, shortness of breath, cough, sputum
Cardiovascular—chest pain, pressure, tightness or fullness, palpitation, cyanosis,
dyspnea or exertion, etc. specify amount of exertion ex. walking one flight of stairs,
walking from chair to bath, or just talking
Peripheral vascular—coldness, numbness and tingling, swelling of legs (time of day
and activity), discoloration of hands or feet, varicose veins, ulcers
Gastrointestinal—appetite, heartburn, indigestion, pain (assoc. with eating), other
ab pain, nausea and vomiting, vomiting blood, black stools, rectal bleeding,
frequency of bowel movement, flatulence
Urinary system—frequency, urgency, nocturia (# of times person wakes up to pee
at night, recent change), dysuria, polyuria, UTI, kidney stones
Male genital system—penis or testicular pain, sores/lesions, penile discharge,
lumps, hernia
Female genital system—menstrual history, vaginal itching, discharge and char, age
at menopause, menopausal signs and symptoms, postmenopausal bleeding
Sexual health—“I usually ask all patients about their sexual health”—then: “are
you presently in a relationship involving intercourse?” contraceptives? STIs?
Musculoskeletal system—history of arthritis or gout. In joints: pain stiffness,
swelling (location, migratory nature, deformity, limitation of motion, noise with
joint motion? In muscles: pain, cramps, weakness, gait problems, coordination
problems? In the back: any pain, stiffness, limitation of motion, history of back pain
or disk disease?
Neurologic System—history of seizure disorder, stroke, fainting, blackouts. Motor
function: weakness, paralysis, coordination problems? Sensory function:
numbness, tingling? Cognitive function: memory disorder (recent or distant,
disorientation?), mental status: nervousness, mood change, depression,
hallucinations, etc
Hematologic System—bleeding tendency of skin or mucous membranes, excessive
bruising, lymph node swelling, blood transfusion and reactions
Endocrine system—history of diabetes or thyroid disease, excessive sweating,
relationship b/w weight and appetite, abnormal hair distribution, tremors,
nervousness, need for hormone therapy
Functional Assessment (including Activities of Daily Living)
Measures a person’s self-care abilities in the areas of general physical health or
absence of illness.
Self esteem/concept: education, financial status, value-belief system (religious)
Activity/exercise: a daily profile reflecting usual daily activities (note ability to
perform ADLs)
Sleep/rest: sleep patterns, day naps, any sleep aids used?
