Summary NUR 1060c Chapter 4 Complete Health History Worksheet

Chapter 4 Complete Health History Worksheet (Student)
Health History Components – Adult p. 41 – **OPEN YOUR LAB MANUAL TO PAGE 25 – 32 TO SEE THE QUESTIONS THAT YOU WILL ASK YOUR PT**
Components Purpose/Information obtained
Biographical Data Patient identification, record primary language, determine need for interpreter

 Source of History (are they reliable?)
Reason for Seeking Care

Present Health or History of Present (detailed below)
Illness (HPI)
Past Health (also called Past Medical Childhood Illnesses
History (PMH))
Accidents/Injuries

Chronic/Serious Illnesses

Hospitalization/Surgeries

Obstetric

Immunization

Allergies

Medications (Prescription/OTC)

Family History
(siblings, parents, grandparents)

Review of Systems (ROS)
(past and present health sorted by body
systems) p. 27-29 in Lab Manual
*Must know your medical terminology*
“Have you had now or in the past the
following…”
Functional Assessment Activities and Exercise (Activities of Daily Living =ADLs)
-Activity & Exercise-profile daily activities to determine level of activity & exercise (p. 29 lab manual)

, Instrumental ADLs (IADLS)