The complete Health History

Question 1

For the ________ person, the history is used to assess his or her lifestyle, including such factors as exercise, healthy diet, substance use, risk reduction, and health promotion behaviors.

Answer 1

Well

Question 2

For the _______ person the health history includes a detailed and chronological record of the health problem.

Answer 2

Ill

Question 3

__________ data include name, address and phone number, age and birth date, birthplace, gender, marital status, race ethnic origin, and occupation

Answer 3

Biographic data

*communication and language needs also need to be included

Question 4

This is a brief, spontaneous statement in the persons own words that describes the reason for the visit. Think of it as the “title” for the story to follow. It states one or two symptoms or signs and their duration

Answer 4

Reason for Seeking Care

Question 5

A_________ is a subjective sensation that the person feels from the disorder

Answer 5

Symptom

Question 6

A _______ is a objective abnormality that you as the examiner could detect on physical examination or in laboratory report

Answer 6

Sign

Question 7

What are the eight critical characteristics?

Answer 7

Location, character/quality, quantity/severity, timing, setting, aggravating/relieving factors, associated factors, and patients perception

Question 8

What do you ask regarding Location ( one of the 8 critical characteristics)?

Answer 8

Ask the person to point to the location
Note precise site of pain
Is pain localized to the site or radiating?
Superficial or deep?

Question 9

What do you ask regarding Character or quality ( one of the 8 critical characteristics)?

Answer 9

This needs specific descriptive terms: burning, sharp, dull, aching, gnawing, throbbing, shooting, viselike.

Question 10

What do you ask regarding Quantity or severity ( one of the 8 critical characteristics)?

Answer 10

Quantify the symptom on a 10 point scale.

Ask how it affects daily activities

Question 11

What do you ask regarding Timing ( one of the 8 critical characteristics)?

Answer 11

When did the symptoms first appear? specific dat and time, and how long ago the symptom started prior to arrival? How long did the symptom last (duration) Was it steady (constant), or did it come and go during that time (intermittent)? Did it resolve completely and reappear days or weeks later ( cycle of remission and exacerbation)?

Question 12

What do you ask regarding setting ( one of the 8 critical characteristics)?

Answer 12

Where was the person or what was the person doing when the symptom first started? What brings it on?

Question 13

What do you ask regarding aggravating or relieving factors of symptoms ( one of the 8 critical characteristics)?

Answer 13

What makes the pain worse? Is it aggravated by weather, activity, food, medication, standing bent over, fatigue, time of day, season and so on? What relieves it? What have you tried?