health history assessment

Health History Assessment

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Health History Assessment Purpose

  • A detailed patient history is the most useful diagnostic tool available to any clinician.
  • The main purpose of the patient’s history is to determine the patient’s motives for seeking health care and how their specific ailment is interfering with their daily life.
  • Surveys show that more than 80% of the diagnosis in general outpatient clinics are based on patient interview based on health history assessment.
  • The patient interview should continue through the entire duration of the interaction with them.
  • The best  general patient history technique is to start with open ended questions, and eventual progress to close-ended questions for details.
  • The accuracy of information collected from the patient during the interview (and exam) influence the precision of your diagnosis and treatment.

Patient Medical Charting Guidelines

  • All chart records must remain confidential.
  • Charting must be clear and legible in order to be useful.
  • Do not erase mistakes or remove pages from the chart. If you must erase an error from the patient’s chart, draw a single line through the error/s and initial.
  • If you saw it or did it, chart it.
  • Charting should be done in black ink, labeled, dated and signed by the clinician who examined the patient.

Health History Considerations

Red Flags for More Serious Pathology

  • Violent trauma
  • Carcinoma
  • Systemic steroid use
  • Drug abuse
  • HIV, Hepatitis
  • Recent unexplained weight loss
  • Constant, progressive non-mechanical pain
  • Bowel and/or bladder dysfunction

Signs and Symptoms Red Flags for More Serious Pathology

  • Temperature > 100° F/37.8°C
  • Blood pressure > 160/95 mm Hg
  • Resting pulse > 100 bpm
  • Resting respiration > 25 bpm
  •  Auscultation of bruits – carotid, abdominal
  • Widespread neurological deficits
  • Saddle anaesthesia

Health History Intake Questions

Occupation 

  • What is your occupation?
  • Describe your activities at work. Hours?
  • Do you like your job?

Exercise 

  • Describe your overall fitness level.
  • Do you participate in regular exercise? (describe type, intensity & frequency)

Interests/Other Activities 

  • Do you have any other interests, hobbies or activities you enjoy?

Diet

  • Rate your overall diet for me (good, fair, poor)
  • What do you eat for … breakfast? Lunch? Dinner? Snacks?
  • What do you drink throughout the day?
  • How often do you eat … vegetables? Fruit? Sweets? Fast food?
  • How much water do you drink a day?

Living Situation 

  • Can you describe your living situation to me? (house/apt., relationships, etc.)

Sleep Pattern 

  • How many hours do you sleep each night?
  • Have there been any recent changes?
  • Do you feel you get enough sleep?

Bowel Habits 

  • How often do you have a bowel movement? Any recent changes?

Patients over 50

Do you ever notice any rectal bleeding?

Urinary Habits

  • Do you have any problems with urination? Any recent changes? (stopping or starting)

Habits

Alcohol: Do you drink alcohol? Type?

How often do you drink? How much?

If you have concern about patient’s drinking:

  • Have you ever felt the need to cut down on drinking?
  • Have you ever felt Annoyed by criticism of drinking?
  • Have you had Guilty feelings about drinking?
  • Have you ever taken a morning “Eye opener?”

Smoking:

  • Do you use or have you ever used tobacco products/smoke? What do you use?
  • How much do you smoke? For how long? When did you stop?

Drugs:

  • Do you use any recreational drugs? What? For how long? (reiterate patient confidentiality if needed)

Domestic Violence

  • Are you currently or have you ever been in a relationship where you were physically hurt or made to feel threatened?

Menses, Menopause 

  • When was the first day of your last menstrual period?
  • Do you have any problems with your menstrual cycle?
  • Have there been any changes in your menstrual cycle? Any abnormal bleeding?

Patients over 50: 

    • Are you still having menstrual periods? If yes, do you remember the first day of your last menstrual period?

Physiologic menopause:

    • At what age did you experience menopause?
    • Did you/are you taking hormone replacement?
    • What? How is it administered?

Surgical menopause: 

    • Why did you have a hysterectomy? (Cancer?)
    • Did they remove your ovaries?
    • Are you taking hormone replacement?

What medication? How is it administered?

Contraceptives, Pregnancies 

  • Contraceptives: Are you using any kind of hormonal contraceptive or an IUD? If yes, what & any problems?
  • Pregnancies: Have you ever been pregnant? If yes, were there any complications?

Medications 

  • Do you take any prescribed medications?
  • Do you take any over the counter medications?
  • Do you take any vitamins?
  • Have you ever taken medication for extended periods of time?
  • E.g., Steroids, antidepressants, NSAIDs, antibiotics, hormones

Allergies 

  • Do you have any allergies? Food, meds, seasonal

Stress factors/Support System 

  • Have there been any significant stresses in your life lately? (e.g.deaths, divorce, family, work)
  • Have you noticed a change in your ability to handle stress?
  • What resources do you have for support for…?

Past Health History Questions

Serious Illness 

  • Have you ever had any serious illness(es)?
  • Any other problems? Residual effects?

Hospitalizations/Surgeries 

  • Have you ever been hospitalized?
  • Have you had any surgeries?

General Trauma, Accidents, Injury

  • Have you experienced any physical trauma that required treatment or should have been treated?
  • Have you had any accidents? MVA?
  • Were there any residual problems or prolonged side effects?

Diagnostic Imaging (x-ray, MRI) 

  • Have you ever had any x-rays? If yes, why?
  • Were there any problems identified on the x-ray?

Prior Care 

  • Have you ever received prior care?
  • If yes, what for? Describe the care. Did it help?
  • This will tell what has & has not worked previously (huge clinical value)

 Last Physical Exam 

  • When was your last physical exam? Were you experiencing your chief complaint when you had the physical?
  • What was it for?
  • Were any problems identified?

Females: 

  • When was your last GYN exam & PAP smear?
  • What were the results?

 Females over 50:

  • Have you had a mammogram? How often?
  • What were the results?

Males 15-35: 

  • Do you perform self-testicular exam?
  • Have you ever been taught how to?

Males over 40: 

Have you ever had a rectal exam or lab tests to evaluate your prostate?

  • If yes, do you remember the results?

Family Health History 

  • Are there any conditions that run in your family (diabetes, high blood pressure, stroke, heart disease, cancer)
  • I’d like to start with your mother. Is she alive? Does she have any health problems?
  • How about your mother’s mother?
  • How about your mother’s father?
  • Your father? Your father’s mother? Your father’s father? Brothers? Sisters?
  • If there is a deceased relative, how old were they when they died? Cause of death?
  • Any other health problems in the family?
  • Consider using a family tree in chart notes