Health History Tool (Student)

FAR EASTERUNIVERSITY
INSTITUTE OF NURSING
AHSE HEALTH HISTORY FACULTY GUIDE
A. BIOGRAPHIC DATA
1. Name
2. Address
3. Age
4. Gender
5. Date of Birth
6. Place of birth
7. Ethnic group
8. Primary language spoken
9. Marital Status
10. Educational
11. Occupation
12. Religious orientation
13. Health Care financing and usual source of medical care
14. Income
B. PAST HEALTH HISTORY

1. Childhood diseases
2. Immunizations
3. Allergies
• drugs
• food
• others
4. Accidents and Injuries
5. Hospitalizations
6. Medications
• prescription
• self prescribed
7. Foreign Travel
C. FAMILY HISTORY OF ILLNESS

1. Health and ages of parents, siblings, children, or ages at death and causes
illness in the family similar to the patient’s
2. Presence of any hereditary diseases: familial incidence of heart disease, rheumatic fever? Hypertension?
Tuberculosis? Diabetes Mellitus? Mental illness? Others?
• Indicate also the genogram of the client (tracing hereditary illnesses/diseases)
FUNCTIONAL HEALTH PATTERNS
D. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

1. How has the general health been? How do you rate your own health?
2. What do you consider healthy about you? What are your health goals?
3. What are traditional concepts of health and illness? Beliefs and practices?
4. Do you have routine physical examination? If yes how often?
5. Perform self breast examination? (female)
6. In the past year how many times have you seen a health care provider? For what reasons?
7. In the past, has it been easy to find ways to follow things nurses/doctors suggest?
8. What safety practices do you follow?
9. Most important things to keep health? You think these things will make a difference to health/ (include
family/ folk remedies if appropriate).
1
10. Personal Hygienic practices: Describe how do you take care of your body? Bath, hand washing, trimming
of fingernails, wearing of slippers, use of deodorant/cologne, brush teeth, flossing, dental visits?
11. Substance use; Use of cigarette, alcohol, drugs? Kind, amount, frequency? Reasons? Aware of effects?
Passive smoking?
12. Environmental condition: adequacy of lighting and ventilation,
13. Environmental sanitation practices: water supply, toilet facilities, waste management, food preparation,
presence of vectors, health hazards
E. NUTRITIONAL AND METABOLIC PATTERN

1. Typical daily food intake? Describe. Supplements?
- 3 day diet recall
2. Typical daily fluid intake? Describe.
3. What is your knowledge of proper nutrition?
4. Food likes and dislikes?
5. Food preparation?
6. Where do you eat?
7. Whom do you eat with?
8. Food budgeting?
9. Weight loss? Gain? Amount?
10. Appetite?
11. Food or eating discomforts? Diet restrictions?
12. Heal well or poorly?
13. Skin problems? Lesions? Dryness?
14. Dental problems?
F. ELIMINATION PATTERN
1. Bowel elimination pattern. Describe. Frequency? Characteristics (color and consistency)? Discomfort/pain?
2. Urinary elimination pattern. Describe. Frequency? Characteristics (color, clarity, odor)? Discomfort/pain?
Problem in control?
3. Practices to achieve normal elimination pattern
4. Excess perspiration? Odor problems?
G. ACTIVITY-EXERCISE PATTERN
1. Describe your usual activities in a day (or week)
2. Kind of physical activity do you engage in? Exercise pattern? Type? Regularity?
Frequency, Intensity, Duration?
3. Are you satisfied with the amount of exercise do you get?
4. What type of work do you do for a living?
5. Sufficient energy for completing desired required activities?
6. Spare time (leisure activities?) Enough resources for leisure activities? Satisfaction?
H. SLEEP-REST PATTERN
1. Describe sleep pattern: Number of hours, Continuity, Satisfied?
2. Usual time to sleep? Usual time for waking up? Do you wake up at night?
3. Do you feel refreshed when you wake up?
4. Describe sleeping environment. Any problems? Concerns?
5. Describe bed time routine
6. Any problem falling sleep?
7. What helps you sleep? (back rub, music or warm milk? Do you take sleep medications?
8. Take naps? When? (morning/afternoon)
9. What do you do for relaxation? (watch movie, read, dance, shopping etc.)
2
I. COGNITIVE-PERCEPTUAL PATTERN
1. Can you read and/or write? Any difficulty?
2. How is your hearing? Hearing difficulty? Aid?
3. How is your vision? Wear eyeglasses? Last checked?
4. Any change in the memory lately?
5. Easiest way to learn things? Any difficulty in learning?
6. Do you have any problems with speaking, reading or writing?
7. Any changes in smell or taste?
8. How are you doing in school/work?
J. SELF-PERCEPTION AND SELF-CONCEPT PATTERN

1. How do you describe yourself? Most of the time, feel good (not so good) about yourself?
2. Changes in your body or the things you can do? Problem to you?
3. Any physical alterations? Changes in way you feel about yourself or your body? Difficulty in acceptance of
changes? How it affects the relationship between you and your family, friends and how you see yourself?
4. How do you see yourself in relation to other people? (better than, equal to or less than)
5. How do you express your thoughts and feelings to others?
6. What are your goals in the next five years? How do you plan to achieve them?
7. Describe characteristics of type of person you would most like to be. Do you see yourself as that person?
8. What type of mood you are usually in? (calm, depressed, pleasant, happy, excited, agitated)
9. Find things that make you angry? Annoyed? Tearful? Anxious? Depressed? What helps?
10. How do you express yourself during mood changes? Do your relations with others change with your
moods? How?
11. Are you satisfied with your usual mood? Why?
K. ROLE-RELATIONSHIP PATTERN
1. Live alone? Family? Family structure? Significant people in life?
2. Describe relationship to each other member of the family
3. Roles assumed in the family. Fulfilled? Why?
4. Any family problems you have difficulty handling? (nuclear/extended)
5. How does your family usually handle problems?
6. Family dependent on you for things? If appropriate? How manage?
7. What do you think of voicing opinions to family? Friends?
8. Who initiates activities with family or with friends?
9. What are usual family activities?
10. Belong to social groups? Close friends? Feel lonely frequently?
11. How do you express your feelings or thoughts to others?
12. Are things generally go well with you at work? (school/college)? Are there any problem in work/school
that influence to health?
13. Income/allowance sufficient for needs? Any financial problems or concerns?
14. Feel part of (or isolated in) neighborhood where living?
L. SEXUALITY-REPRODUCTIVE PATTERN
1. How do you express yourself as a man/ as a woman? Any difficulty or problems in expressing ones
sexuality?
2. How do you show affection to others? How do you want others to show affection?
3. Any concerns regarding fertility or family planning?
4. Do you engage in high risk sexual practice?
5. If appropriate: any changes or problems in sexual relations?
6. If appropriate: use of contraceptives? Problems?
7. Female: when menstruation started? Last menstrual period? Menstrual problems?
3
M. COPING-STRESS TOLERANCE PATTERN
1. Describe a stressful event for you
2. How do you handle stress or pressure? Effective? Satisfied? Why/why not?
3. Tense a lot of time? What helps? Use of any medicine? Drugs? Alcohol?
4. Who’s most helpful in talking things over? Available to you now?
5. Any big changes in your life in the last year or two?
6. When (if) have big problems (any problems) in your life, how do you handle them?
7. Most of the time, is this (are these) way(s) successful?
N. VALUE-BELIEF PATTERN
1. What makes a person healthy?
2. How important is health to you?
3. Any spiritual or religious practices important to you? Relevance to health?
4. Do you generally get things you like out of your life? Most important things to you?
5. Is religion important in your life? Does this help when difficulties arise?
6. What social values you were brought up with? Which ones are important to you now?
7. How do you see yourself in relation to society?
O. OTHERS
1. Any others things that we haven’t talked about that you’d like to mention? Questions?
References:
Alfaro, Rosalinda, Applying Nursing diagnosis and Nursing process: A Step by step guide (J.B. Lippincott Co, Philadelphia) 1990
Christensen, Paula anhd Kenney, Janet, Nursing Process: Application of Conceptual Models (C.V. Mosby Co, Missouri) 1990
Craven,
Gordon, Marjorie, Manual of Nursing Diagnosis (Mosby Yearbook Inc. Missouri) 1995
Kozier, Barbara, Fundamental of Nursing. (Addison-Wesley Publishing Co.) 2001

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FAR EASTERUNIVERSITY

AHSE HEALTH HISTORY FACULTY GUIDE

B. PAST HEALTH HISTORY

C. FAMILY HISTORY OF ILLNESS

FUNCTIONAL HEALTH PATTERNS

D. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

E. NUTRITIONAL AND METABOLIC PATTERN

J. SELF-PERCEPTION AND SELF-CONCEPT PATTERN

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