Health History Form

General Survey
Name: _________________________________________________ Date: _____________

Age: _____Gender: ________Marital Status: __________ Race: _____________ Ethnicity:
_________
Culture: ___________ Religion: ______________________ Occupation:
______________________
Health Insurance: _________________ Source of Information/Reliability:
____________________
Date of Last Visit:
History
Review of history related to the reason for the client’s visit:
Focused symptom analysis of current problem:
Reason seeking health care:

__________________________________________________________________________
Description of present problem:
Onset: ___________________________________________________________
Duration: ___________________________________________________________
Location: ___________________________________________________________
Severity: ___________________________________________________________
Associated problems: ___________________________________________________________
Efforts to treat: ___________________________________________________________
Health beliefs and practices: ___________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
Health patterns/general health status: ____________________________________________________
Sleep/rest/stress-reduction patterns: ____________________________________________________
_______________________________________________________________________
General Survey Page 1 of 5
©2006 Pearson Education, Inc.

Current medications (Rx, OTC, complimentary): ___________________________________________-
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Allergies: ___________________________________________________________________________
_____________________________________________________________________________________
Past Medical History

Past medical problems: _____________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Hospitalizations and surgery: _______________________________________________________

___________________________________________________________________________________
Primary care:
___________________________________________________________________________________
___________________________________________________________________________________
Childhood illnesses:
___________________________________________________________________________________
___________________________________________________________________________________
Immunizations: ____________________________________________________________________
__________________________________________________________________________________
Mental and emotional health:

__________________________________________________
_______________________________________________________________________
Substance use: __________________________________________________________
Family History
Immediate family: __________________________________________________________________
Extended family: ___________________________________________________________________
Genogram:

Psychosocial History:
Occupational history: ______________________________________________________

Education: ______________________________________________________________
Financial background: ________________________________________________________________
Roles and independence: _______________________________________________________________
_____________________________________________________________________________________
Family: ______________________________________________________________________________
Social structure: ______________________________________________________________________
Emotional concerns: __________________________________________________________________
Self-concept: _________________________________________________________________________
Current Medical History/Review of Systems:
YES/NO If YES, provide details:

Review of Systems
_______________________________________________
Nutrition ______________________________________________
_______________________________________________
Hair, skin, nails ______________________________________________
_______________________________________________
Head and neck ______________________________________________
_______________________________________________
Lymphatics ______________________________________________
_______________________________________________
Eyes/vision ______________________________________________
_______________________________________________
Ears/hearing ______________________________________________
_______________________________________________
Nose, mouth, throat ______________________________________________
_______________________________________________
Respiratory system ______________________________________________
_______________________________________________

Cardiovascular ______________________________________________
_______________________________________________
Circulatory or peripheral vascular_____________________________________________
_______________________________________________
_______________________________________________
Breasts and axillae ______________________________________________
Abdomen/gastrointestinal ______________________________________________
_______________________________________________
Musculoskeletal ______________________________________________
_______________________________________________
Neurological ______________________________________________
_______________________________________________
Female reproductive ______________________________________________
Male reproductive ______________________________________________
Mental health ______________________________________________
Rectal, bowels, prostate ________________________________________________
Analysis:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

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General Survey

Name: _________________________________________________ Date: _____________

Review of history related to the reason for the client’s visit:

Focused symptom analysis of current problem:

Reason seeking health care:

Health beliefs and practices: ___________________________________________________________

Health patterns/general health status: ____________________________________________________

Sleep/rest/stress-reduction patterns: ____________________________________________________

General Survey Page 1 of 5

©2006 Pearson Education, Inc.

Past Medical History

Hospitalizations and surgery: _______________________________________________________

Mental and emotional health:

Substance use: __________________________________________________________

Immediate family: __________________________________________________________________

Extended family: ___________________________________________________________________

General Survey Page 2 of 5

©2006 Pearson Education, Inc.

Occupational history: ______________________________________________________

Current Medical History/Review of Systems:

YES/NO If YES, provide details:

General Survey Page 3 of 5

©2006 Pearson Education, Inc.

Male reproductive ______________________________________________

Mental health ______________________________________________

Rectal, bowels, prostate ________________________________________________

General Survey Page 4 of 5

©2006 Pearson Education, Inc.

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Name: _____________________________________ Date: _