Health History Form
Jocelyn5483Assistance with completing a Health History Form today before 9pm
3 years ago
20
files (1)HealthHistoryForm.docx
HealthHistoryForm.docx
Name Date
Directions Using the Health History Guidelines and Rubric complete the chart below with your participant. Please review the rubric prior to gathering your data to assure proper completion of the assignment.
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Criteria |
Data |
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BIOGRAPHICAL DATA |
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Date |
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Initials |
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Age |
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Date of birth |
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Birthplace |
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Gender |
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Marital status |
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Race |
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Religion |
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Occupation |
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Reliability of source of information |
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PRESENT HEALTH HISTORY/ILLNESS |
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When do they seek care |
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Current health status |
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Health goals |
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HEALTH BELIEFS AND PRACTICES |
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Beliefs and practices (exercise patterns, alcohol/drug use, how do they get to work, do they wear a seat belt) |
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Factors influencing healthcare decisions |
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MEDICATIONS |
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Prescription medications |
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Over-the-counter medications |
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Herbals |
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PAST HISTORY |
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Childhood diseases |
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Immunizations |
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Allergies |
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Major illnesses |
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Injuries |
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Hospitalizations |
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Pregnancies and deliveries |
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Surgeries |
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EMOTIONAL HISTORY |
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emotional psychiatric or substance use related problems |
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FAMILY HISTORY |
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Father |
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Mother |
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Siblings |
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Grandparents |
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PSYCHOSOCIAL/ OCCUPATIONAL HISTORY |
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Support systems |
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Occupational history |
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Educational level |
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Is money a source of concern |
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ROLES AND RELATIONSHIPS |
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Participant’s roles and relationships |
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Community based activities |
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ETHNICITY AND CULTURE |
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Ethnicity and culture |
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Social traits that influence healthcare decisions |
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SPIRITUALITY |
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Religious and spiritual needs |
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SELF-CONCEPT |
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View of self-worth (who and what they are) |
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Future goals |
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REVIEW OF SYSTEMS (Please refer to your assignment guidelines. This is NOT a physical assessment.) |
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Skin, hair, nails |
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Head, neck, related lymphatics |
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Eyes |
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Ears, nose, mouth, and throat |
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Respiratory |
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Breasts and axillae |
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Cardiovascular |
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Peripheral vascular |
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Abdomen |
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Endocrine |
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Urinary |
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Reproductive |
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Musculoskeletal |
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Neurologic |
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