Health history

MIAMI DADE COLLEGE

MEDICAL CENTER CAMPUS BENJAMÍN LEÓN SCHOOL OF NURSING

NUR 3069: ADVANCED HEALTH ASSESSMENT

Health History Format

I. Identifying Data/Source of the History and Reliability

a. Name

b. Address

c. Age

d. Date of Birth

e. Birthplace

f. Gender

g. Marital Status

h. Race

i. Ethnic Identity/Culture

j. Religion and Spirituality

k. Occupation

l. Health Insurance

m. Source of Referral n. Source of Information and Reliability

II. Chief Complaint(s)

III. Present Illness

a. Reason for Seeking Care

b. Health Beliefs & Health Practices

c. Health Patterns (habits of smoking and alcohol)

d. Medications (prescriptions and over the counter)

e. Allergies

IV. Past Health History

a. Adult illnesses with dates for at least four categories: Medical, Surgical, Obstetrics/Gynecologic, and Psychiatric.

b. Hospitalizations

c. Outpatient Care

d. Childhood Illnesses

e. Mental and Emotional Health

f. Health Maintenance practices (immunizations, screening tests, lifestyles issues, and home safety)

V. Family History – outlines or diagram age and health, or age and cause of death, of siblings, parents, and grandparents. Please provide both narrative and genogram including:

a. Narrative history of immediate and extended family

b. Genogram

VI. Personal and Social History

a. Occupational History

b. Educational level

c. Financial background

d. Roles and Relationships

e. Family origin and Culture

f. Social Structure and Emotional Concerns

g. Self-Concept and Self-Esteem

h. Functional assessment & Safety measures

i. Personal interests

VII. Nutritional Data and Health Promotion Activities

a. Provide a 24-hour diet recall of the patient b. Types of health promotion activities that the patient currently practices

VIII. Developmental Data and Theories (see Module 1)

a. Select at least two theories (these could be nursing or other theories) to

identify developmental aspects of your patient.

IX. Review of Systems – Narrative recording of presence or absence of common symptoms related to each major body system listed below stated by the patients/families:

a. Skin, Hair, and Nails

b. Head, Eyes, Ears, Nose, Throat (HEENT)

c. Neck

d. Breasts and Axillae

e. Respiratory

f. Cardiovascular

g. Peripheral vascular

h. Gastrointestinal

i. Musculoskeletal

j. Neurologic

k. Urinary

l. Male or Female Reproductive

X. Analysis of Findings: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________