The Complete Health History
The Complete Health History
Purpose of a Health History
Collect subjective data: This information is gathered from the patient's perspective and combined with objective data (from physical exams and lab studies) to form a comprehensive patient database.
Provides a complete patient picture: Offers a full understanding of the patient's past and present health status.
Screening tool: Can be used to detect abnormalities.
Documentation: Available in printed or electronic format for review, validation, and updates.
Variability in sequence: The order of obtaining information may differ.
Context-dependent focus: The emphasis can change based on the clinical practice setting or the nature of the complaint.
The Health History Sequence
General Sequence
Biographic data
Reason for seeking care
Present health or history of present illness (HPI)
Past medical history
Medication Reconciliation
Family history
Review of systems (ROS)
Functional assessment, including activities of daily living (ADLs)
Health History for Adults
Record date and time
Biographic data
Source of history
Reason for seeking care
Present health or history of present illness
Past health
Family history
Review of systems
Functional assessment including ADLs
Additional questions for special populations
Components of the Health History
Biographic Data
Name, address, and phone number.
Age, birth date, and birthplace.
Gender and preferred pronoun, relationship status.
Race and ethnic origin.
Occupation: usual and present.
Primary language; note if a language-concordant provider or medical interpreter is needed.
Source of History
Record informant: Typically the patient, but could be a relative or friend.
Judge reliability: Assess the informant's consistency of information and willingness to communicate.
Note special circumstances: For example, the use of an interpreter.
Reason for Seeking Care
Patient's own words: A brief, spontaneous statement describing the reason for the visit. Document in quotes.
Symptom: A subjective sensation the person feels from a disorder (e.g., patient states, "I feel dizzy").
Sign: An objective abnormality that can be detected on physical examination or in laboratory reports (e.g., a rash, elevated blood pressure).
Not a diagnostic statement: The reason for care should describe the complaint, not label it as a diagnosis.
Prioritized reasons: Focus on the patient's main concerns.
Present Health or History of Present Illness (HPI)
Collect comprehensive data: Identify and elaborate on eight critical characteristics of the symptom.
Eight Critical Characteristics:
Location: Be precise (e.g., point to the exact spot on the body).
Character or quality: Use descriptive terms (e.g., burning, throbbing, sharp, dull).
Quantity or severity: Use scales to quantify intensity (e.g., pain scale of 1 to 10).
Timing: Onset (when it started), duration (how long it lasts), and frequency (how often it occurs).
Setting: The location or associated activity when the symptom started.
Aggravating or relieving factors: What makes the symptom worse or better.
Associated factors: Is the concern related to any other symptoms?
Patient's perception: How does it affect the patient's life or activities?
Precision and accuracy: Ensure collected data is exact.
Measurable standards: Use quantitative measures or the patient's exact words as qualifiers.
Standardized indicators: Document findings using consistent reporting methods.
Reliability and validity: Ensure the reported results are trustworthy and accurate.
PQRSTU Mnemonic
A mnemonic to help organize the sequence of questions for obtaining all relevant symptom data:
P = Provocative or palliative (What brings it on? What makes it better or worse?)
Q = Quality or quantity (How does it look, feel, sound? How intense/severe is it?)
R = Region or radiation (Where is it? Does it spread anywhere?)
S = Severity scale: 1 to 10 (How bad is it? Is it getting better, worse, or staying the same?)
T = Timing or onset (When did it start? How often does it occur?)
U = Understand patient's perception of the problem (What do you think it means? How does it affect you?)
Example of a Well-Written Chief Complaint
A good example: "Patient complaining of chest pain for about 3 days that is worse with activity and relieved with rest." This provides location, timing, and aggravating/relieving factors.
Past Medical History
Impact on health: Each identified area can have a residual impact on present and future health status.
Specific pertinent information: Focus on obtaining detailed information for each category.
Clinical decision-making: More accurate and detailed information leads to better decisions.
Coping insights: Provides cues on how patients cope with illness or health concerns.
Categories of Past Health
Childhood illnesses: Document experienced or exposed illnesses, including presence or absence of complications.
Accidents or injuries: Note the type, nature, and any acute or residual deficits, along with dates.
Serious or chronic illnesses: Identify the presence of comorbidities and their pronounced effect.
Hospitalizations: Record types (based on clinical indications), interventions used, length of stay, and dates.
Operations: Document the facility, name of healthcare provider, and date of procedures.
Obstetric History: Relevant data related to childbearing, including:
GPAL: Gravida (pregnancies), Para (live births), Abortions (miscarriages or induced abortions), Living children.
Labor/delivery experience.
Condition of the infant.
Postpartum course.
Immunizations: Correlate with CDC Guidelines.
Last Examination Date: Obtain recent data for common labs/diagnostics (e.g., blood work, ECG, chest x-ray, occult blood, and gender-specific testing like PAP/PSA).
Allergies: Clearly note the allergen and the specific reaction (e.g., rash, anaphylaxis).
Current Medications: Perform medication reconciliation, including prescribed, over-the-counter (OTC) medications, and herbal therapies.
Family History
Genetic risk: Highlights diseases or conditions an individual may be at risk for due to genetics.
Relative information: Provides age and health status, or cause of death, of relatives.
Proactive measures: This information enables early screening, lifestyle adjustments, and/or periodic surveillance.
Genogram (Pedigree): A standardized tool used to organize and visualize family history data.
Symbols: (as shown in the transcript image)
Square: Male
Circle: Female
Diagonal line through symbol: Deceased
Triangle: Pregnancy loss (include weeks if known)
Diamond: Undetermined gender or total number of children if individual details are unknown.
Solid lines connecting individuals show family relationships (e.g., marriage, parent-child).
Dashed line: Adopted.
Broken line (two parents with line between them): Divorced/not together.
Additional Questions for Immigrants
Biographic data: Inquire about the country of origin and entry into the current country.
Spiritual resources and religion: Assess if certain medical procedures or dietary practices conflict with religious beliefs.
Past health: Ask about past immunizations, if any, received in their home country.
Health perception: Explore how the person defines health and illness and how they perceive their current problems.
Nutrition: Inquire about taboo foods or food combinations due to cultural or religious beliefs.
Genetics and Environment
Direct-to-consumer DNA testing: Increased availability provides information on ancestry, family relationships, nutrition, and genetic variants.
Professional follow-up: Findings from such tests should be followed up with a genetic counselor and/or healthcare provider.
Validation: Test results should be validated by health professionals.
Review of Systems (ROS)
Purpose of ROS
Evaluate past and present health: Assess the current and historical state of each body system.
Comprehensive data capture: Ensure all pertinent data related to each body system has been noted.
Health promotion assessment: Evaluate the patient's health promotion practices related to each system.
Approach to ROS
Cephalocaudal approach: Proceed in a logical, head-to-toe sequence.
Avoid redundancy: If information was already obtained in the HPI, it does not need to be reassessed.
Facilitate communication: Use clear, understandable language; translate medical terms for the patient.
Record presence or absence of symptoms: Avoid writing "negative" for body systems; instead, specify if symptoms are present or absent.
Limit to subjective data: Do not include objective data from the physical exam; focus solely on patient statements.
Include all relevant systems: Document pertinent information for the individual patient.
Health promotion focus: Address health promotion for each identified area.
Systems to Review
General overall health state: Fatigue, weakness, fever, chills, weight changes.
Skin, hair, and nails: Rashes, lesions, itching, changes in hair or nails.
Head: Headaches, head injury, dizziness.
Eyes and ears: Vision changes, pain, discharge, hearing changes, tinnitus.
Nose and sinuses: Nasal discharge, nosebleeds, sinus pain.
Mouth and throat: Sores, bleeding gums, toothache, sore throat, difficulty swallowing.
Neck: Lumps, pain, stiffness, swollen glands.
Breast and axilla: Lumps, pain, discharge, rash, tenderness.
Respiratory: Cough, shortness of breath, wheezing, pain with breathing.
Cardiovascular: Chest pain, palpitations, edema, high blood pressure.
Peripheral vascular: Leg pain, cramps, varicose veins, swelling.
Gastrointestinal: Abdominal pain, nausea, vomiting, diarrhea, constipation, appetite changes, heartburn.
Urinary: Frequency, urgency, pain with urination, blood in urine, incontinence.
Male/Female genital system & sexual health: Lesions, discharge, pain, sexual difficulties.
Musculoskeletal: Joint pain, stiffness, swelling, muscle pain, weakness, limited range of motion.
Neurologic: Seizures, tremors, weakness, numbness, tingling, difficulty speaking, memory changes.
Hematologic: Bleeding, bruising, anemia, swollen lymph nodes.
Endocrine: Excessive thirst, urination, heat/cold intolerance, sweating, changes in hair/skin.
Functional Assessment
Activities of Daily Living (ADLs): Self-care activities vital for general health status.
Objective measurement: Used to objectively measure functional status and monitor changes over time.
Lifestyle data: Gathers relevant data related to lifestyle and living environment.
Sensitive topics: May include sensitive topics (e.g., intimate partner violence, substance use) requiring attention to privacy.
Key Areas of Functional Assessment
Self-esteem, self-concept: How the person feels about themselves.
Activity/exercise: Daily activities, exercise patterns.
Sleep/rest: Sleep patterns, difficulties.
Nutrition/elimination: Dietary intake, bowel and bladder habits.
Interpersonal relationships/resources: Social support network.
Spiritual resources: Role of spirituality or religion.
Coping and stress management: Mechanisms for handling stress.
Personal habits: Tobacco, alcohol, marijuana use (type, quantity, frequency).
Illicit or street drugs: Any use of illegal substances.
Environment/hazards: Home and work environment safety, exposure to toxins.
Intimate partner violence: Screening for domestic abuse.
Occupational health: Job satisfaction, perceived work stressors, exposures.
Perception of Health
Patient's perspective: Ask questions to understand the patient's personal view of health and illness:
"How do you define health?"
"How do you view your situation now?"
"What are your concerns?"
"What do you think will happen in the future?"
"What are your health goals?"
"What do you expect from your healthcare team?"
Developmental Competence: Health History for Children
Adaptation: The health history for a child adapts sections from the adult health history.
Age and development specific: Includes information specific to the child's age and developmental stage.
Early life details: Comprehensive details on pregnancy, labor and delivery, and the perinatal period.
Nutritional data: Focus on nutrition as it relates to growth and development.
Parenting and family: Information on parenting practices and family role relationships.
Information source: Depending on the child's age, information may be obtained from a parent or caregiver.
Past Health History for Children
Context of developmental age: Information is obtained and interpreted within the child's developmental stage.
Dual communication: Often involves communicating with both the parent/caregiver and the child to gather information.
Coping insights: Provides cues on how the patient (child) and parent cope with illness/health concerns.
Prenatal, perinatal, and postnatal status: All pertinent data related to the childbirth experience.
Childhood illnesses: Listing of age, types of illnesses, and potential complications.
Serious Accidents or injuries: Age of occurrence, types of injury, treatment received, and/or possible complications.
Serious or chronic illnesses: Age of onset, types of diseases, treatment, and/or possible complications.
Operations or Hospitalizations: Reason for care, age at admission, length of stay, treatment, intervention, hospital facility location, physician/provider, type of surgery, date, and reaction to hospitalization.
Immunizations & Allergies: Correlate with CDC recommendations per established guidelines according to age; indicate allergen and response; discriminate between true food allergy and food intolerance.
Medications: Include information about prescribed, OTC, and herbal therapy; obtain information related to vitamin supplements (dosage, schedule, clinical indication).
Developmental History:
Growth and developmental milestones.
Document activity response to established milestones.
Continually assess and reassess growth and developmental achievements across the life cycle.
Nutritional History:
Information collected varies with the child's age.
For infants: Calorie and nutrient composition with attention to breast or bottle-feeding.
For older children: Introduction of solid food patterns and continued assessment of caloric and food intake throughout childhood.
Family History: Obtain pertinent information through interview and a genogram.
Review of Systems for Children
Similar method: The same method of inquiry used with adults is adapted for children.
Organized approach: Maintain a systematic review.
Multiple informants: Include at least two individuals (parent/caregiver and/or child).
Age-appropriate communication: Differences focus on cognitive and developmental age-appropriate behaviors.
Focus: General overall health state, specific body systems (indicators, health promotion), and gender-specific systems (indicators, health promotion).
Functional Assessment for Children
Family unit context: Consider the child's position within the family unit.
ADLs for child and family: Focus on how ADLs relate to both the child and the family unit.
Key areas:
Interpersonal relationships
Activity and rest
Economic status
Home environment and environmental hazards
Coping/stress management
Habits
Health promotion
Adolescent Health History: HEEADSSS Mnemonic
A method of interviewing adolescents that focuses on several key areas:
Home environment
Education and employment
Eating habits
Activities (peer related)
Drugs (alcohol, tobacco, illicit substances)
Sexuality
Suicide and depression
Safety from injury and violence