CHA AHP

HEALTH HISTORY GUIDELINES

I. Subjective Data: (What the Patient Tells You; S of SOAP note)

Identification: Name, address, age, race, sex, referring care provider, etc. (For Class only

use initials, Sex, Age)

Informant: Self or relationship to patient, reliability

Chief Complaint (CC): Use patient’s own words and place in quotes; why are they seeking

care?

History of Present Illness (HPI): describes CC fully— Use OLDCHARTS acronym to fully

describe any abnormal reports. Include: diagnostic testing, home treatment, medical

treatment; risk factors and pertinent negatives as applicable

Past Medical History (PMH): Record positives/pertinent negatives of the following:

 Current Meds: Over-the-counter, home/folk remedies, and prescriptions including

PRNs only if used frequently: current and pertinent previous medications.

 Allergies: To medications, foods, environment and how they manifest

 Surgeries: Blood transfusions, anesthesia experiences, adverse reactions with

dates

 Hospitalizations/non-surgical with dates

 Trauma Injuries with dates

 Current and past Health Problems: record all disease processes including dates

of onset and current status of disease.

 Infectious Diseases: Ask about all active diseases and all immunizations

recommended by the CDC for pt’s age group. Health Maintenance (age/sex

appropriate):

1. Children: prenatal/birth history, immunization status, feeding/dietary

patterns, sleeping patterns; car seat/helmet use

2. Females: Last pelvic/PAP, breast self-exam/mammogram, colon; safety

measures

3. Male: testicular self-exam, prostate exam, colon; safety measures

 Usual state of Health with functional assessment: indicate the nature of living

quarters, ability to ambulate and perform ADL including meal prep. Laundry,

driving, use of assistive devices.

 Recent laboratory or diagnostic testing: give dates and results of recent testing

Family History: Age, current status, major medical problems of all blood relatives including

Grandparents, Parents, Siblings, Aunts/Uncles, Nieces/Nephews, Cousins, Children,

Grandchildren

Psychosocial History: Family/support structure, past/present occupations/ military service,

life stressors, risk factors/habits (alcohol, tobacco, caffeine, illicits, 24 hour diet recall,

exercise patterns, environmental exposures). Insurance, education level, religion, hobbies,

beliefs. Occupation.

Pediatrics: Grade, school success/problems, sleep/play patterns and developmental delays.

Domestic Violence History: history of violence or threats of violence. Threats to safety.

Review of Systems (ROS), (Always include pertinent negatives)

 General: Weight loss/gain; fatigue, weakness, appetite, fever/chills

 Skin, Hair & nails: Rash, pruritis, bruising, dryness, lesions, skin cancer, usual

self-care, hair loss, change in texture, nail ridges, nail color and texture

 Head: Trauma, headache, dizziness, fainting

 Eyes: Vision or visual field changes; corrective lenses; date of last exam;

diplopia, blurring, burning, discharge/dry eyes; cataracts, glaucoma.

 Ears: Hearing changes, tinnitus, pain, discharge, vertigo, frequent ear infections

 Nose: Change or loss of sense of smell, epistaxis, obstruction, polyps, sinus

problems.

 Mouth/Throat: Date last dental exam, bleeding gums, painful teeth, mouth

ulcers/lesions, hoarseness, frequent pharyngitis; Tonsils removed or intact,

changes in taste; snoring/sleep apnea.

 Respiratory (Resp): Chest pain, sneezing/wheezing, dyspnea; amount/color of

sputum; hemoptysis. History of pneumonia, flu, PPD or BCG (last chest X-ray)

 Cardiovascular (CV): Chest pain, orthopnea, dyspnea with exertion, nocturnal

dyspnea, murmurs, palpitations, peripheral edema.

 Peripheral Vascular: Intermittent claudication, peripheral edema, varicosities,

DVT history, cold/pale extremities, slow healing of distal limb wounds.

 GI: Dysphagia, heartburn, nausea/vomiting, hematemesis, indigestion, abdominal

pain (location, nature), diarrhea/constipation, stool frequency, consistency, color;

jaundice, fatty food intolerance. Date of last Bowel movement.

 Gyne: Age of onset menses—frequency, duration, flow, regularity,

dysmenorrhea; Date of last menstrual period. Contraceptive use/history;

Gravida/Para/Abortions (spontaneous/elective); complications during pregnancy

(DM, Eclampsia, Prematurity). STDs. Breast lesions, biopsies, galactorrhea. Age

of menopause/perimenopause; Hormone Replacement. Sexual history: Frequency,

# of partners, sexual orientation/satisfaction, dyspareunia.

 GU: Frequency, hesitancy/change in stream, dysuria, hematuria, polyuria,

polydipsia, nocturia, incontinence. Males: Lesions, discharge, STDs; sterility,

libido, impotency; Sexual history: Frequency, # of partners, sexual

orientation/satisfaction.

 Endocrine: Polyuria, polydipsia, polyphagia, temperature intolerances,

glycosuria, changes in hair, skin texture, fatigue, weight changes, goiter.

 Musculoskeletal (MSK): Joint pain/swelling; trauma, erythema, tenderness,

warmth; limitation in ROM, spinal/back pain/injury; history of gout, arthritis.

 Hematologic (Heme): Cold intolerance, fatigue, bleeding tendency, bruising,

lymphadenopathy; history of anemia

 Neurological (Neuro): Syncope, seizure, weakness; changes in coordination/

sensation.

 Psychiatric (Psych): Changes in mood, memory, sleep patterns, nervousness,

emotional disturbances, substance abuse.

Summary of findings: List findings in the history