Marking Scheme New Update
what is the purpose of a complete health history? - Answer- ✔✔to collect subjective
data and to get a complete picture of a person's past and present health
what is involved in a complete health history of a well person? - Answer- ✔✔lifestyle,
exercise, diet, substance use, risk reduction, health promotion
affirm what they are doing right
what is involved in a complete health history of an ill person? - Answer- ✔✔information
about the health problem
what is the health history sequence? - Answer- ✔✔1. Biographic data
2. Source of history
3. Reason for seeking care
4. Present health or history of present illness
5. Past history
6. Family history
7. Review of systems
8. Functional assessment or activities of daily living (ADLs)
biographical data - Answer- ✔✔Name
Address and phone number
Age and birth date
Birthplace
Sex
Marital status
Race
Ethnic origin
Occupation: usual and present
source of history - Answer- ✔✔Record who furnishes the information, judge how reliable
the informant seems and how willing, note any special circumstances
(how reliable is the person providing the information?)
reason for seeking care - Answer- ✔✔Brief, spontaneous statement in the person's own
words that describes the reason for the visit
symptom - Answer- ✔✔subjective sensation person feels from disorder
o What person says is reason for seeking care is recorded and enclosed in "quotation
marks" to indicate person's exact words
, sign - Answer- ✔✔objective abnormality that can be detected on physical examination
or in laboratory reports
Present Health or History of Present Illness (HPI) - Answer- ✔✔Location (where is the
pain)
Character or quality (burning, sharp, dull)
Quantity or severity (using pain scale)
Timing (when did the symptoms appear)
Setting (where/what were you doing when symptoms started)
Aggravating or relieving factors (What makes pain better or worse)
Associated factors (review symptoms related to that body system)
Patient's perception
HPI and PQRST - Answer- ✔✔mnemonic for pain and symptom
P/P: Provocative or palliative
Q/Q: Quality or quantity
R/R: Region or radiation
S: Severity scale: 1 to 10
T: Timing or onset
U: Understand patient's perception of problem
Past Health History - Answer- ✔✔-Childhood illnesses (Which ones, how old?)
Accidents or injuries (When, what kinds, lasting effects?)
-Serious or chronic illnesses (HTN, DM, CKD, Lungs... how long, how managed?)
-Hospitalizations
-Operations (When, what, recovery?)
-Obstetric history
-Immunizations
-Last examination date
-Allergies (Note both allergen and reaction)
-Current medications (Med Rec. Prescription and OTC meds and Herbal)
Family Health History - Answer- ✔✔a record of any illnesses or medical conditions that
have afflicted members of a person's family
Functional Assessment - Answer- ✔✔screens the safety of independent living, the need
for home health services, and quality of life, THIS INCLUDES ADLs
for a health history on new immigrants what should be included - Answer- ✔✔o
Biographical data
o Spiritual resource and religion: assess if certain procedures cannot be done
o Past health: what immunizations, if any
o Health perception
o How does person describe health and illness
o How does person see problems he or she is now experiencing