Subjective Data

NAME: PHONE:
ADDRESS: GENDER:
PROVIDER OF HISTORY: BIRTH DATE:
ETHNIC BACKGROUND: PLACE OF BIRTH:
PRIMARY/SECODARY LANGUAGE: MARITAL STATUS:
EDUCATIONAL LEVEL: RELIGION:
OCCUPATION:
REASON/S FOR SEEKING HEALTHCARE:
HISTORY OF PRESENT HEALTH CONCERN

CHARACTER: (How does it feel, look, smell, sound, etc.?)
ONSET: (When did it begin? Is it better, worse, or the same since it began?)
LOCATION: (Where is it? Does it radiate?)
DURATION: (How long does it last? Does it recur?)
SEVERITY: (How bad is it on a scale of 1 to 10?)
PATTERN: (What makes it better? What makes it worse?)
ASSOCIATED FACTORS: (What other symptoms do you have with it? Will you be able to continue doing your work or
other activities?
PAST HEALTH HISTORY

PROBLEMS AT BIRTH:
CHILDHOOD ILLNESSES:
IMMINICATOIN TO DATE:
ACUTE/CHRONIC ILLNESSES: (Physical, Emotional, Mental)
SURGERIES:
ACCIDENTS:
PROLONGED PAIN/PAIN PATTERNS:
ALLERGIES:
MEDICATIONS:
FAMILY HEALTH HISTORY
RECALL AS MANY GENETIC
RELATIVES AS POSSIBLE (parents,
grandparents, siblings) WITH AGE,
LONGEVITY, CHRONIC ILLNESSES
(i.e., heart disease, stroke, diabetes,
cancer, arthritis, Alzheimer’s).
REVIEW OF SYSTEMS
SKIN, HAIR, AND NAILS: (Skin color, temperature, condition,

excessive sweating, rashes, lesions, balding, dandruff, condition
of nails)
HEAD AND NECK: (Headache, swelling, stiffness of the neck,
difficulty swallowing, sore throat, enlarged lymph nodes)
EYES: (Vision, eye infections, redness, excessive tearing, halos
around lights, blurring, loss of side vision, moving black
spots/specks in visual fields, flashing lights, double vision, and
eye pain)
EARS: (Hearing, ringing or buzzing, earaches, drainage from
ears, dizziness, exposure to loud noises)
MOUTH, THROAT, NOSE, AND SINUSES: (Condition of teeth
and gums; sore throats; mouth lesions; hoarseness; rhinorrhea;
nasal obstruction; frequent colds; sneezing or itching of eyes,
ears, nose, or throat; nose bleeds; snoring)
THORAX AND LUNGS: (Difficulty breathing, wheezing, pain,
shortness of breath during routine activity, orthopnea, cough or
sputum, hemoptysis, respiratory infections)
BREASTS AND REGIONAL LYMPHATICS: (Lumps or
discharge from nipples, dimpling or changes in breast size,
swollen or tender lymph nodes in axilla)
HEART AND NECK VESSELS: (Last blood pressure, ECG tracing
or findings, chest pain or pressure, palpitations, edema)
PERIPHERAL VASCULAR: (Swelling, or edema, of legs and
feet; pain; cramping; sores on legs; color or texture changes on
the legs or feet)
ABDOMEN: (Indigestion, difficulty swallowing, nausea,
vomiting, abdominal pain, gas, jaundice, hernias)
MALE GENITALIA: (Excessive or painful urination, frequency or
difficulty starting and maintaining urinary stream, leaking of
urine, blood noted in urine, sexual problems, perineal lesions,
penile drainage, pain or swelling in the scrotum, difficulty
achieving an erection and difficulty ejaculating, exposure to
sexually transmitted infections)
FEMALE GENITALIA: (Sexual problems; sexually transmitted
diseases; voiding problems (e.g., dribbling, incontinence);
reproductive data such as age at menarche, menstruation
(length and regularity of cycle), pregnancies, and type of or
problems with delivery, abortions, pelvic pain, birth control,
menopause (date or year of last menstrual period), and use of
hormone replacement therapy)
ANUS, RECTUM, AND PROSTATE: (Bowel habits, pain with
defecation, hemorrhoids, blood in stool, constipation, diarrhea)
MUSCULOSKELETAL: (Swelling, redness, pain, stiffness of
joints, ability to perform activities of daily living, muscle
strength)
NEUROLOGIC: (General mood, behavior, depression, anger,
concussions, headaches, loss of strength or sensation,
coordination, difficulty speaking, memory problems, strange
thoughts and/or actions, difficulty learning)
LIFESTYLE AND HEALTH PRACTICES PROFILE

DESCRIPTION OF TYPICAL DAY:
Please tell me what an average or typical day is for you. Start by waking up in the morning and going until bedtime.
NUTRITION AND WEIGHT MANAGEMENT:

What do you usually eat during a typical day? Please tell me the kinds of foods you prefer, how often you eat throughout
the day, and how much you eat.
Do you eat out at restaurants frequently?
Do you eat only when hungry? Do you eat because of boredom, habit, anxiety, depression?
Who buys and prepares the food you eat?
Where do you eat your meals?
How much and what types of fluids do you drink?
ACTIVITY LEVEL AND EXERCISE:

What is your daily pattern of activity?
Do you follow a regular exercise plan? What types of exercise do you do?
Are there any reasons why you cannot follow a moderately strenuous exercise program?
What do you do for leisure and recreation?
Do your leisure and recreational activities include exercise?
SLEEP AND REST:

Tell me about your sleeping patterns.
Do you have trouble falling asleep or staying asleep?
How much sleep do you get each night?
Do you feel rested when you awaken?

Do you nap during the day? How often and for how long?
What do you do to help you fall asleep?
SUBSTANCE USE:
How much beer, wine, or other alcohol do you drink on average?
Do you drink coffee or other beverages containing caffeine (e.g., cola)? If so, how much and how often?
Do you no or have you ever smoked cigarettes or used any other form of nicotine? How long have you been smoking/did
you smoke? How many packs per week? Tell me about any efforts to quit
Have you ever taken any medication not prescribed by your healthcare provider? If so, when, what type, how much, and
why?
Have you ever used, or do you now use, recreational drugs? Describe any usage.
Do you take vitamins or herbal supplements? If so, what?
SELF-CONCEPT AND SELF-CARE RESPONSIBILITIES:

What do you see as your talents or special abilities?
How do you feel about yourself? About your appearance?
Can you tell me what activities you do to keep yourself safe, healthy, or to prevent disease?
Do you practice safe sex?
How do you keep your home safe?
Do you drive safely?
How often do you have medical checkups or screenings?
How often do you see the dentist or have your eyes (vision) examined?
SOCIAL ACTIVITIES:
What do you do for fun and relaxation?
With whom do you socialize most frequently?
Are you involved in any community activities?
How do you feel about your community?
Do you think that you have enough time to socialize?
What do you see as your contribution to society?

RELATIONSHIPS:
Who is (are) the most important person(s) in your life? Describe your relationship with that person.
What was it like growing up in your family?
What is your relationship like with your spouse?
What is your relationship like with your children?
Describe any relationships you have with significant others.
Do you get along with your in-laws?
Are you close to your extended family?
Do you have any pets?
What is your role in your family? Is it an important role?
Are you satisfied with your current sexual relationships? Have there been any recent changes?
VALUES AND BELIEF SYSTEM:

What is most important to you in life?
What do you hope to accomplish in your life?
Do you have a religious affiliation? Is this important to you?
Is a relationship with God (or another higher power) an important part of your life?
What gives you strength and hope?
EDUCATION AND WORK:

Tell me about your experiences in school or about your education.
Are you satisfied with the level of education you have? Do you have future educational plans?
What can you tell me about your work? What are your responsibilities at work?
Do you enjoy your work?

How do you feel about your coworkers?
What kind of work-related stress do you have? Any major problems?
Who is the main provider of financial support in your family?
Does your current income meet your needs?
STRESS LEVELS AND COPING STYLES:

What types of things make you angry?
How would you describe your stress level?
How do you manage anger or stress?
What do you see as the greatest stressors in your life?
Where do you usually turn for help in a time of crisis?
ENVIRONMENT:
What risks are you aware of in your environment such as in your home, neighborhood, on the job, or any other activities in
which you participate?
What types of precautions do you take, if any, when playing contact sports, using harsh chemicals or paint, or operating
machinery?
Do you believe you are ever in danger of becoming a victim of violence? Explain.

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NAME: PHONE:

HISTORY OF PRESENT HEALTH CONCERN

LOCATION: (Where is it? Does it radiate?)

DURATION: (How long does it last? Does it recur?)

SEVERITY: (How bad is it on a scale of 1 to 10?)

PATTERN: (What makes it better? What makes it worse?)

PAST HEALTH HISTORY

SKIN, HAIR, AND NAILS: (Skin color, temperature, condition,

LIFESTYLE AND HEALTH PRACTICES PROFILE

NUTRITION AND WEIGHT MANAGEMENT:

Do you eat out at restaurants frequently?

Who buys and prepares the food you eat?

Where do you eat your meals?

How much and what types of fluids do you drink?

ACTIVITY LEVEL AND EXERCISE:

What do you do for leisure and recreation?

Do your leisure and recreational activities include exercise?

SLEEP AND REST:

Do you have trouble falling asleep or staying asleep?

How much sleep do you get each night?

Do you feel rested when you awaken?

What do you do to help you fall asleep?

Do you take vitamins or herbal supplements? If so, what?

SELF-CONCEPT AND SELF-CARE RESPONSIBILITIES:

How do you feel about yourself? About your appearance?

Do you practice safe sex?

How do you keep your home safe?

Do you drive safely?

How often do you have medical checkups or screenings?

With whom do you socialize most frequently?

Are you involved in any community activities?

How do you feel about your community?

Do you think that you have enough time to socialize?

What do you see as your contribution to society?

What was it like growing up in your family?

What is your relationship like with your spouse?

What is your relationship like with your children?

Describe any relationships you have with significant others.

Do you get along with your in-laws?

Are you close to your extended family?

Do you have any pets?

What is your role in your family? Is it an important role?

VALUES AND BELIEF SYSTEM:

What do you hope to accomplish in your life?

Do you have a religious affiliation? Is this important to you?

What gives you strength and hope?

EDUCATION AND WORK:

Do you enjoy your work?

What kind of work-related stress do you have? Any major problems?

Who is the main provider of financial support in your family?

Does your current income meet your needs?

STRESS LEVELS AND COPING STYLES:

How would you describe your stress level?

How do you manage anger or stress?

What do you see as the greatest stressors in your life?

Where do you usually turn for help in a time of crisis?

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