Taking a Health History Ms. Rica A. Santos, RN

Objectives Describe the purpose of a health history. Describe the steps in taking a complete health history. Identify appropriate questions to ask throughout the health history. Describe a method for exploring a patient’s symptoms/complaints. Identify appropriate questions for the Review of Systems. Describe a functional assessment and identify

Complete Health History Biographic data Reasons for Seeking Health Care History of Present Health Care Past Health History Family Health History –Genogram

Review of Systems Skin, hair, and nails Head and neck Eyes Ears Mouth, throat, nose and sinuses Thorax and lungs Breasts and regional lymphatics Heart and neck vessels

Review of Systems Peripheral vascular Abdomen Genitalia Anus, rectum, and prostate Musculoskeletal Neurologic

Lifestyle and Health Practices Description of a typical day Nutrition and weight management Anxiety level and exercise Sleep and rest Medication and substance use Self-concept and Self-care Responsibilities Social Activities

Lifestyle and Health Practices Relationships Value and belief System Education and work Stress levels and coping styles Environment

Developmental Level Trust vs. Mistrust Autonomy vs. Shame and Doubt Initiative vs. Guilt Industry vs. Inferiority Identity vs. Role Confusion Intimacy vs. Isolation Generativity vs. Stagnation Ego-integrity vs. Despair