2. Components of Nursing Health History
1. Biographic Data
2. Chief Complaint
3. History of Present Illness
4. Past Illness
5. Family History of Illness
6. Lifestyle
7. Social Data
8. Psychological Data
9. Patterns of Health Care
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4. Biographic Data
This includes the following:
a. Complete Name of the
Patient
b. Complete Address
c. Age and Birthdate
d. Gender / Sex
e. Marital Status
f. Occupation
g. Religious Affiliation
h. Health Care Financing
i. Usual Source of Medical
Care
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6. Chief Complaint
• The answer given to the
question:
“What is troubling you?”
or
“What brought you to the
hospital or clinic?”
Note:
The chief complaint
should be recorded in the
client’s own words.
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8. History of Present Illness
The following questions should be considered:
1. When the symptoms started?
2. Whether the onset of the symptoms was sudden or
gradual?
3. How often the symptoms occur?
4. Exact location of the distress?
5. Character of the complain (e.g. Intensity of pain, quality of
sputum, emesis, discharge, etc.)
6. Activity in which the client was involved when the problem
occurred.
7. Phenomena or symptoms associated with the chief
complaint.
8. Factors that aggravate or alleviate the problem.
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10. Past Illness
1. Childhood Illnesses:
Such as chickenpox, mumps,
measles, rubella (German
Measles), Rubeola (Red
Measles), Rheumatic Fever,
Streptococcal Infections, and
other Significant Illnesses.
2. Childhood Immunization
• This includes BCG, DPT,
Measles, Hep – B, Influenza
Shots, Tetanus Shots (last
dose taken), OPV, and other
vaccines received by the
patient.
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11. Past Illness
3. Allergies to drugs, animals,
insects, or other
environmental agents and type
of reaction that occurs.
4. Accidents and injuries
• How, where, when the
incident occurred, type of
injury acquired, treatment
received, and any
complications
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12. Past Illness
5. Hospitalization for Serious
Illnesses
• Reason for hospitalization,
Dates, Surgery Performed,
Course of Recovery, and any
complications.
6. Medications
• All currently used
prescriptions and over the
counter medications such as
aspirin, nasal spray,
vitamins, laxatives,
maintenance drugs, etc.
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14. Family History of Illness
• To ascertain risk factors for
certain diseases, the ages of
siblings, parents, and
grandparents and their
current state of health, or if
they are deceased, the
cause of death are
obtained.
• Particular attention should
be given to disorders such
as heart disease, cancer,
diabetes, hypertension,
obesity, allergies, arthritis,
tuberculosis, bleeding
problems, alcoholism, and
any mental health
disorders.
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16. Lifestyle includes:
1. Personal Habits
• The amount, frequency, and
duration of substance use
such as tobacco, alcohol,
coffee, cola, tea, and illicit
or recreational drugs.
2. Diet
• Description of a typical diet
on a normal day or any
special diet, number of
meals and snacks per day,
who cooks and shops for
food, ethnically distinct
food patterns, and allergies.
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17. Lifestyle includes:
3. Sleep / Rest Pattern
• Usual number of hours of
sleep (at night and nap
time), Usual time of sleep
and usual wake time,
sleeping difficulties and the
remedies used.
4. Activities of Daily Living
• A random list, in an hour
per hour basis of daily
activities.
• Any difficulties experienced
in the basic activities of
eating, grooming, dressing,
elimination, and
locomotion.
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18. Lifestyle includes:
5. Instrumental Activities of
Daily Living
• Any difficulties experienced
in food preparation,
shopping, transportation,
housekeeping, laundry,
ability to use telephone /
cellphone, handle finances,
and manage medications.
6. Recreation / Hobbies
• Exercise activity and
tolerance, hobbies and
other interests, and
vacations.
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20. Social Data includes:
1. Family relationships /
friendships
• The client’s support system
(who helps in times of
need?)
• What effect the client’s
illness has on the family?
• Any family problems are
affecting the client?
2. Ethnic Affiliation
• Health customs and beliefs
• Cultural practices that may
affect health care and
recovery
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21. Social Data includes:
3. Educational History
• Data about the client’s
highest educational
attainment.
• Any past difficulties with
learning.
4. Economic Status
Information about how the
client is paying for medical
care (including what kind of
medical or medical coverage
the client has), or whether the
client’s illness presents
financial concern.
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22. Social Data includes:
5. Occupational History
• Current employment status?
• Number of days missed because
of illness?
• Any history of accidents on the
job?
• Any occupational hazards with a
potential for future disease or
accidents?
• The client’s need to change job
because of past illness?
• Employment status of the
spouse?
• The way childcare is handled?
• Client’s overall satisfaction with
the work?
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23. Social Data includes:
6. Home and Neighborhood
Conditions
• Home safety measures and
adjustments in physical
facilities that may be
required to help the client
manage a physical disability,
activity intolerance, and
activities of daily living.
• Availability of neighborhood
and community services to
meet the client’s needs.
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25. Psychological Data includes
1. Major stressors
experienced and the
client’s perception of
them.
2. Usual coping pattern with a
serious problem or high level
of stress.
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26. Psychological Data includes
3. Communication Style
• Ability to verbalize
appropriate emotions.
• Non – verbal
communication such as eye
movement, gestures, use of
touch, and posture.
• Interactions with support
persons.
• Congruence of non – verbal
behavior and verbal
expression.
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28. Patterns of Health Care
• All health care resources the
client is currently using and has
used in the past.
• These includes the family
physician, specialists
(ophthalmologist, Obstetrician,
cardiologist, etc.)
• Use of health clinic or health
centers, albulario, herbalist, hilot,
faith healers, etc.
• Is access to health care a
problem, and know the reason
why.
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