Find a patient, such as a friend or family member, to conduct an entire health history interview. Use the Health History Guideline attatched to

Health History Guideline

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Use this guide to gather patient information for the Comprehensive Health History Assignment.

Subject Criteria Possible Points

Patient Demographics • Gender, age, ethnicity, and other social

demographics as indicated (self-pay, Insurance) 5

Chief Complaint

• In the patient's own words, describe one or more symptoms or concerns that cause the patient to seek care.

• Elaborate on the chief complaint; describe how each symptom developed.

• Include the patient's thoughts and feelings about the illness.

5

History of Present

Illness

• Appropriate dimensions of cardinal symptoms are listed (including location, severity, quality, setting, chronology, aggravating/alleviating, and associated manifestations)

• HPI narrative flows smoothly in a logical fashion

• For those students who favor mnemonics, the 8 dimensions of a medical problem can be easily recalled using OLD CARTS (Onset, Location/radiation, Duration, Character, Aggr avating factors, Relief factors, Timing, and Severity).

10

Past Medical History

• Lists childhood illnesses

• Lists adult illnesses with dates for at least three categories: medical, surgical, and psychiatric.

• Medication, Allergies

• List patient's health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety.

5

Current Health Status • Summary of general health status related to the

present illness. 5

Health History Guideline

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Family History

Narrative and

Genogram

https://genopro.com/geno

gram/medical/

• Outlines or diagrams of age and health or age and cause of death of siblings, parents, grandparents, and children.

• Documents the presence or absence of specific illnesses in the family (e.g., hypertension, coronary artery disease)

• The family pedigree shows at least three generations and involves standardized symbols, which mark individuals affected with a specific diagnosis to allow for easy identification.

10

Risk Assessment

Based on Family

History

• Family history of a known or suspected genetic condition

• Ethnic predisposition to certain genetic disorders

• Consanguinity (blood relationship of parents)

• Multiple affected family members with the same or related disorders

• Earlier than expected age of onset of disease

• Diagnosis in less-often-affected sex

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Social History

• Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur?

• Do they drink alcohol? If so, how much per day and what type of drink?

• Any drug use, past or present, should be noted.

• Work, family, friends, community support systems,

5

Past Surgical History

• Were they ever operated on, even as a child?

• What year did this occur?

• Were there any complications?

5

Health History Guideline

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Sexual Activity

• Do they participate in intercourse? With persons of the same or opposite sex?

• Are they involved in a stable relationship?

• Do they use condoms or other means of birth control?

• If married? The health of the spouse? If divorced? Past sexually transmitted diseases?

• Do they have children? If so, are they healthy? Do they live with the patient?

5

Work/Hobbies/Other

• What sort of work does the patient do?

• Have they always done the same thing? Do they enjoy it?

• If retired, what do they do to stay busy? Any hobbies?

5

Review of Systems

(ROS)

• Document the presence or absence of common symptoms related to each central body system.

• Consider asking a series of questions going from "head to toe."

• The questions asked to reflect an array of standard and critical clinical conditions (heart disease, diabetes, arthritis) explicitly prompt the patient,

• Format o General/skin/sleep o HEENT o Respiratory o Cardiovascular o Musculoskeletal o Endocrine o Gastrointestinal and Urinary o Neuro/psych

10

Prevention and Health

Promotion

• List at least one prevention activity.

• List at least three health promotion recommendations.

10

Health History Guideline

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APA Guidelines &

Writing Style

• APA (title page, margins, page numbers, headings, subheadings, citations); spelling; writing straightforward, concise, and professional.

10

Total 100