TAKING a HEALTH
HISTORY
NCM 101 – Health Assessment
1st Semester, AY 2020-2021
Prepared by:
Ms. Alida L. Marallag, RN, MHPEd
September 14, 2021
College of Nursing School of Nursing and Allied Health Sciences
St. Paul University Philippines
Learning Objectives:
• At the end of the session, the students
should be able to:
o define health history
o discuss the purpose of obtaining a health
history
o identify the components of a nursing
health history
o demonstrate effective skills in taking a
health history
HEALTH HISTORY
➢ a collection of client-centered data or
information which provides a
comprehensive picture of a person’s
health status
➢ serves as the basis for identifying a
client’s health strengths, needs and
problems
➢ obtained through an interview
Purpose of taking a Health
History
• Taking the health history provides
➢focus on the patient’s health and illness
status
➢data from the patient’s perspectives
➢opportunity to establish rapport with
client/s
➢a direction for physical examination
Components a Health History
• Biographical (demographic) data
• Chief complaint
• History of present illness
• History of past illness
• Family history – illnesses in the family
• Lifestyle
• Social support system
• Psychological data
• Values and beliefs
BIOGRAPHICAL DATA
• information to be obtained include
➢ name (initials would do – to maintain
confidentiality)
➢ age
➢ sex
➢ marital status – married, single, divorced,
widowed, widower
➢ educational attainment
➢ occupation – specify trade or profession
➢ religion
CHIEF COMPLAINT
• specifies the reason/s which prompted
the client to seek medical advice or
admission
• better recorded in the client’s own words
example: - difficulty of breathing
- severe abdominal pain
- dry cough for 2 weeks
- burning sensation on
urination
- headache
HISTORY of PRESENT ILLNESS
• specifies and elaborates the chief complaint/s
➢ time when symptoms started or were
experienced
➢ onset of symptoms – sudden or gradual
➢ frequency of the problem
➢ exact location of the distress or complaint
➢ character of the complaint – intensity, duration,
etc…
➢ activity or event that triggered the problem
➢ factors that aggravate or alleviate the problem
HISTORY of PAST ILLNESS
• also called PAST MEDICAL-SURGICAL
HISTORY
• provides a quick look at a client’s previous health
status and illness experiences
o this include
➢ childhood illnesses
➢ childhood immunizations
➢ allergies – to drugs, food, environmental agents,
animal danders
➢ accidents and injuries – what, where, when and how;
treatment received
➢ hospitalization – dates and length of admission;
course of treatment
➢ medications – over-the-counter or maintenance
FAMILY HISTORY
• to screen, detect and ascertain risk factors for
diseases
• information include
o age and health status of parents, siblings,
grandparents, relatives who have diseases
such as:
✓ heart disease
✓ allergies
✓ cancer
✓ obesity
✓ diabetes
✓ mental health disorders
✓ hypertension
✓ bleeding
LIFESTYLE
• refers to the values and behaviors adapted
by a person in daily life which could make
him/her healthy or ill
• this include
➢personal habits
➢diet
➢sleep-rest patterns
➢activities of daily living (ADLs) – also
include exercise and engagement in
sports
➢recreation or hobbies
DEVELOPMENTAL LEVEL
• assessment is focused on the person’s
➢developmental milestones
➢developmental tasks
• based on different theoretical frameworks
➢ Psychosexual (Freud)
➢ Psychosocial (Erikson)
➢ Cognitive (Jean Piaget)
➢ Moral (Kohlberg)
PSYCHOSOCIAL HISTORY
• these pertain to the client’s coping
and stress management
• these include
➢major stressors and client’s
perceptions of them
➢usual coping pattern
➢communication styles
VALUES and BELIEFS
• these refer to the client’s principles,
morals and philosophy that are held
dearly
• those interpretations or conclusions
that the client accepts as true
• these include the belief in God,
goodness, honesty, integrity, health,
etc…
INTERVIEW and TAKING
HEALTH HISTORY in
ACTION
Sample Questions
and Rationale
BIOGRAPHIC DATA
Data Rationale
⚫ The patient’s entire name need not be written to
Name or maintain anonymity and confidentiality of
Initials of the information obtained.
patient
⚫The patient has the right to protection from undue
embarrassment and any form of indignity
Date of birth
⚫ To help plan appropriate care, communicate
properly and to use approaches suited for the
Age
patient’s profile and personal context.
Sex/Gender
BIOGRAPHIC DATA
Data Rationale
Nationality ⚫ To communicate properly.
⚫ This will provide information as to whether an
interpreter will be needed during the interview.
Religion ⚫ To consider preferences and prohibitions
in interventions for reason of faith
Occupation ⚫ These data reveal the patient’s economic
status and educational preparation.
⚫ Information are valuable to the plan of care
Highest particularly on the approaches that could
educational best suit the patient’s needs.
attainment
CHIEF COMPLAINT/S
Questions Rationale
Reason/s for
coming to the
hospital
⚫What is troubling ⚫ Answers to these questions initiate
you? direction and focus to further assessments.
⚫ What brought you
to the hospital
today?
⚫ Answers tell exactly the nature of the
client’s problem/s.
HISTORY of PRESENT ILLNESS
Questions Rationale
When did the symptoms ⚫These questions initially
start? provide the information about the
chief complaint.
What were you doing at
that time? These include the history of the
⚫
present illness and health
concerns - most important
Was the onset of symptoms factors that will assist the health
sudden or gradual? team to make the diagnosis and
determine patient’s needs.
HISTORY of PRESENT ILLNESS
HISTORY of PRESENT ILLNESS
Questions Rationale
Has
Whenthe didproblem occurred ⚫ These
the symptoms There questions
are associated
initially
before?
start? manifestations
provide - usuallyabout the
the information
chief complaint.
significant positive and
negative findings that occur
How often does the with theinclude
chief complaints.
What were you doing at ⚫ These the history of the
problem occur?
that time? present illness and health
concerns - most important
⚫ These questions gives
What factors aggravate factors that will
information on assist the health
the origin or
Was the onsetthe
and alleviate problem? team
of symptoms extenttoofmake the diagnosis
the problem andas
as well
sudden or gradual? determine patient’s needs.
the diagnosis.
What home remedies did
you try problem
Did the to solve occur
the ⚫ Answers will lead the nurse to
before?
problem? the particular body system that
is/are involved in the problem/s.
HISTORY of PAST ILLNESS
Questions Rationale
What childhood ⚫ Obtaining information about past
illnesses did you medical history will provide
have? additional factors to consider when
planning care.
What immunizations
have you received?
⚫ Answers or data obtained could be
Did you have any used as baseline information
accidents or injuries specially when the chief complaint
that required is related with the current health
hospitalization? When status.
and where did you
receive treatment?
HISTORY of PAST ILLNESS
Data Rationale
Is this your first time in
the hospital? ⚫Obtaining information about
** If no, where, when past medical history will provide
and why were you additional factors to consider
hospitalized before? when planning care.
Are you presently taking
⚫ Answers or data obtained could
prescription or over-the-
be used as baseline information
counter medications?
specially when the chief
** If yes, what are these? complaint is related with the
current health status.
How long have you been
taking them?
HISTORY of PAST ILLNESS
Data Rationale
Is this your first time in
the hospital? ⚫Obtaining information about
** If no, where, when past medical history will provide
and why were you additional factors to consider
hospitalized before? when planning care.
Are you presently taking
⚫ Answers or data obtained could
prescription or over-the-
be used as baseline information
counter medications?
specially when the chief
** If yes, what are these? complaint is related with the
current health status.
How long have you been
taking them?
FAMILY HISTORY
Questions Rationale
Do you have any family
history of chronic illnesses, ⚫ Identifying diseases that may be
e. g. diabetes mellitus, heart genetic are important information
disease, hypertension, sickle to plan care of patient.
cell, cancer?
What is the current health ⚫ The data would also give a clue
status of your family to the health team to include the
members (parents, siblings, family in the plan of care.
grandparents, other relatives)
Does any family member
have a similar health problem
as yours? Who among the
members? What is the
current health status of that
member?
LIFESTYLE – Personal Habits
Data Rationale
Do you smoke?
** If smoking, since when? ⚫ Some behaviors put patients at
risk.
How many sticks do you
consume in a day? ⚫ Answers will give information
that could be related to the chief
Do you drink alcohol? complaints and assist the nurse
** If yes, since when? in further planning of care.
How many glasses/bottles ⚫ Health teachings and
of alcohol do you promotion of healthy lifestyle
consume in a day? can be done for the patient at a
later time.
LIFESTYLE – Activity/Exercise
Data Rationale
What physical activities do ⚫These provide information
you usually do? about the patient’s level of
mobility and tolerance to
activities.
Do you have any difficulty
doing physical activity? ⚫ These can be related to the
** If yes, specify the difficulty chief complaints and guide
or difficulties. physical assessment.
LIFESTYLE – Nutrition/Diet
Data Rationale
How many times do you
eat in a day?
⚫ These provide the nutritional status
Describe your typical of the patient, dietary and eating
diet or meal. patterns.
⚫These can be related to the chief
Do you follow any
complaints and guide physical
SPECIAL diet?
assessment.
** If yes, specify.
What foods do you like
to eat?
LIFESTYLE – Nutrition/Diet
Data Rationale
Have you noticed any
change in your appetite
lately? ⚫ These provide the nutritional status
of the patient, dietary and eating
Do you have any patterns.
difficulty in eating?
** If yes, specify the
difficulty or difficulties. ⚫These can be related to the chief
complaints and guide physical
assessment.
Have you gained or lost
weight lately?
Are you happy with
your patient weight?
LIFESTYLE – Sleep/Rest Patterns
Question Rationale
How many hours do you sleep
in a day?
Do you have any sleeping
problems?
**If yes, specify the difficulty ⚫ These provide information on
or difficulties. the sleep patterns of the
patient and may reveal
What did you do to cope with
problems.
your sleeping problem?
How do you feel when you
wake up in the morning?
Do you take naps?
**If yes, specify your usual
snap time.
LIFESTYLE – Elimination
Data Rationale
How often do you pass
urine?
Do you have any problems
passing urine? ⚫ These provide information on
**If yes, specify the the elimination patterns and may
difficulty or difficulties. reveal actual or potential
problems.
How often do you move
your bowels?
Do you have any problems
passing stools?
** If yes, specify the
difficulty or difficulties.
SOCIAL SUPPORT SYSTEM
Data Rationale
With whom do you
live?
Who supports you in
times of problems or ⚫ These questions assess the family
illness? structure, patterns of communication,
presence or absence of a support
How is hospitalization system that could contribute to a
affecting your family patient’s health and well-being.
and work?
Are there any thing or
concerns that worry
you about being sick
and in the hospital?
PSYCHOSOCIAL: Stress and Adaptation
Data Rationale
What are the things
that make you upset
or stressed? ⚫These questions will help the
What do you do when nurse assess the patient’s coping
you have problems? patterns and level of strengths that
can be utilized in the plan of care.
What is your
perception or attitude
about your present
hospitalization?
VALUES and BELIEFS
Data Rationale
What things do you
consider as important ⚫Spirituality is part of the patient’s
and valuable? health and illness condition.
What religious and ⚫ Spiritual values and beliefs affects
cultural practices are a person’s behavior and approach
important to you? to health problems and response to
illness.
References:
Kozier, B. et al. (2008). Fundamentals of Nursing: Concepts, Process
and Practice. (8th Ed.).New Jersey, Pearson-Prentice Hall.
Weber, J. et al. (2014). Health Assessment in Nursing. (5th Ed.).
Philadelphia, Lippincott
Photo credits:
1. COLDSPAA – https://nursessity.wordpress.com/2015/02/19/physical-assessment-memorization-tricks/coldspa/
2. Interview - Creator: KatarzynaBialasiewicz | Credit: Getty Images/iStockphoto Copyright: KatarzynaBialasiewicz
