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History taking for nursing students
- 1. History Taking i. Biographicaldata Name: _________ Medical diagnosis: _________ Age: _________ Occupation: _________ Gender: _________ Admission date: _________ Via: __________ Address:_________ Race: _________ Religion: _________ Birth date/ place: _________ Blood type:_________ Sourceof data: _________ Parent's education: Mother_______ /Father________ Date of interview: ___________
- 2. ii. Chief complaint/Reason for seeking care (cc) (One or two major symptom + their last occurrence before admission) ______________________________________________ ______________________________________________ iii. Present illness (PI) asbbreviatedA.obtain all details related to the chief complaintTo( )P.Q.R.S.T.U.A P Palliative/what can decrease the symptom: ________________________ Provocative/ what can increase the symptom: _____________________ ___________________________________________________________
- 3. Q Quality/ how canyou describe the symptom: ______________________ R Region/ where has the symptom occurred on your body:______________ Radiation/ does it radiate to other parts of the body. If yes, where: _____ S Severity/ on a pain scale of 1-10, how much is your pain: _____________ T Timing Onset/ when & how did the pain or symptom start: _________________ __________________________________________________________ Duration/ for how long does it last: ________________________ ______
- 4. Frequency/ how manytimes a day does it happen: __________________ U (Quoted statement from the patient or parents) Understanding/ what did you thought the symptom is indicating for: "____________________________________________________ _____________________________________________________" A Associated factors/was the symptom associated with other symptoms: ___________________________________________________________ Write present illness as a paragraph
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- 6. iv. Past illness(ph) A- Birth history If patient is under 2 years, collect it: / mother health during pregnancy, any illness (HTN, DM,Pregnancy- hemorrhage), or any infections: _________________________________ X-ray: ______________ nutrition: _____________ Gestation time : _________months Were problems faced during past pregnancy, yes/no. What were They? ________________________________________________ ______________________________________________________ / when did your contractions first start: ________________Labor How often were your contractions coming: _________________ Were they getting stronger_________werethey regular________ .vaginal or cesarean: Was itDelivery :Child condition at birth Crying: yes/ no Basic problems ( with respiration..ect):______________________
- 7. Birth injury: Yes/no.What was it ________________ Birth weight: __________kg Skin color: cyanosis ( ) jaundice ( ) fever ( ) rash ( ) B- Previous illnesses, injuries, or operations Previous illnesses: _____________________________________ Injuries: __________________________when________________ Surgical operations/ pervious hospitalization: Cause_________________________________________________ Date__________________________________________________ Treatment_____________________________________________ C- Allergies Does the patient have allergies from food, medication, any other agents like pets, or house hold products, what is the reaction? _____________________________________________________ ________________________________________________ D- Current medications ___________________________________________________________
- 8. ___________________________________________________________ ImmunizationsE- The name ofthe disease/vaccination: ___________________________ The number of injections: ______________________________________ ___________________________________________________________ The ages when administered: ___________________________________ The dosage(was the dosageof the vaccinations lessened or did they give it to the patient fully):_________________________________________ __________________________________________________________ Vaccination not given_____________cause_______________ HabitsF- Hours of sleep and arising:___________________________________
- 9. Regularity of stoolsand urination/ how many times a day: ___________________________________________________________ G- Growth and development Growth •Approximate/current weight at 6 months, 1 year, 2 years, and 5 years of age: ________________________________________________________ •Approximate/current length at ages 1 and 4 years: _________________________________________________________ Head/chest circumference: _______________________________________________________ •Dentition, including age of onset, number of teeth, and symptoms during teething: ___________________________________________________________ Developmental milestones include: Gross motor: • Age of holding up head steadily: _______________________________ Can patient sit/ walk:______________________________________ Age of sitting alone_____________________walking____________ Fine motor:
- 10. Can patientHold a spoon/draw/pickup something:_______________ Smiling: ________ Language: • Age of saying first words with meaning: _________________________ Can patient talk/understand what others say:_____________________ Sociality: • Interactions with other children, peers, and adults:__________________ Other questions: • Present grade in school: ______________________________________ • Scholastic performance:______________________________________ • If the child has a best friend:__________________________________ H- Family medical history (used primarily to discover any hereditary or familial diseases inthe parents and child.) chronic illnesses in the tree family of patient parents, their immediate aunts and uncles, and their grandparents ( heart problems, hypertension, cancer, obesity, cancer, DM…etc) Age of mother______ Father ________ Illness (HTN, DM..etc): mother_________ ____father_______________ Siblings: How many_______ age of each______________________ _________________________________illness__________________ Grandparents: Age of grandmother _______grandfather_______ If anyone deceased name cause/ date: ___________________________________________________________ ___________________________________________________________
- 11. I- Family structure: •Family composition: _____________________________________ • Home and Community Environment: _______________________ • Monthly income: _______________________________ • Occupation and Education of Family Members:________________ ______________________________________________________ ______________________________________________________ G- Feeding history/ diet/ nutrition assessment(significant in child less than 2 years): • Type of feeding: breast fed Yes/No. If yes, duration_____________ Bottle fed Yes/No. if yes, at which age_______, composition of formula______________________, amount_____________ml, frequency/day____________ • Supplements (iron, vitamins..etc): ___________________ ________________________________________________ • Current diet:______________________________________ K- PsychosocialHistory: Fears: adaption/regression:
- 12. Vital sings Normal range accordingto age resultVital sings Temperature pulse Respiratory rate Blood pressure O2saturation Lab test Normal range ResultChemistryNormal range ResultCBC Na+WBC K+RBC CL-HCT CA+HGB BunLYMPH CRTMONO GLUNeutro Platelet URIANLYSIS: STOOLCLUTURES: CSF:
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