Initials, age, race/ethnicity, gender, occupation. Include a sentence of who is providing the health history.
Perception of Health
Provide the client’s perception of health—include what they stated in quotation marks.
Past Medical History
Include the client’s past medical history
Family Medical History
Include medical history for mother, father, siblings, maternal and paternal grandparents
Continue documenting the health history as described in the RUA guidelines and from the information in chapter 4 of your text. I advise using headings, to ensure that you address all components of the assignment. When you get to the review of systems, it can be documented this way, for example:
Review of Systems
Head
Denies history of trauma, states frequent headaches for the last 3 weeks, occurring daily in the afternoon (this is an example—you document what your client told you)
Skin
Denies history of eczema, psoriasis, rashes. States freckles on cheeks and nose (again—document what your client told you)
Eyes
Continue as before. If the client does not have any concerns, document denies _______, ________, and ______, using the information from chapter 4 to guide you in the specific questions to ask regarding each body system.