The document outlines the components of a standard patient health history, including biographic data, chief complaint, history of present illness, past health history, family history, socio-cultural history and medications, environmental history, and for obstetric/gynecological cases, obstetrical history. It describes the key information gathered in each section, such as identifying information, reason for visit, onset and progression of current issues, past medical conditions and surgeries, family medical history, social activities and substance use, and living environment risks. The health history lays the groundwork for identifying nursing problems and guiding the physical exam.

1. HEALTH HISTORY
The health history is an excellent way to begin the
assessment process because it lays the
groundwork for identifying nursing problems and
provides a focus for the physical examination.
Biographic Data
• Usually include information that
identifies the client such as name,
address, age, gender, civil status,
birthdate, birthplace, nationality,
religion, educational level, occupation,
who provided the information – the
client or significant others, date and time
of interview.
CHIEF COMPLAINT: Reason for
Hospitalization
• Examples of chief complaints:
• Chest pain for 3 days
• Swollen ankles for 2 weeks
• Fever and headache for 24 hours
HISTORY OF PRESENT ILLNESS
• This takes into account several aspects of
the health problem and asks questions
whose answers can provide a detailed
description of the concern.
• First encourage the client to explain the
health problem or symptom in as much
detail as possible by focusing on the
onset, progression, and duration of the
problem; signs and symptoms and
related problems; and what the client
perceives as causing the problem.
• You may also ask the client to evaluate
what makes the problem worse, what
makes it better, which treatments have
been tried, what effect the problem has
had on daily life or lifestyle, what
expectations are held about recovery, and
what is the client’s ability to provide self-
care.
• The mnemonic COLDSPA (Character,
Onset, Location, Duration, Severity,
Pattern, and Associated factors/ how it
affects the client) is designed to help the
nurse explore symptoms, signs, or health
concerns.
PAST HEALTH HISTORY
• This portion of the health history focuses
on questions related to the client’s past,
from the earliest beginnings to the
present.
• Information covered in this section
includes questions about birth, growth,
development, childhood diseases,
immunizations, allergies, previous health
problems, hospitalizations, surgeries,
pregnancies, births, previous accidents,
injuries, pain experiences, and emotional
or psychiatric problems.
FAMILY HISTORY
• The purpose of family health history is to
learn about the general health of the
client’s blood relatives, spouse, and
children and to identify any illness of
environmental, genetic or familiar nature
that might have implications for the
client’s health problems.
• The family history should include as
many genetic relatives such as the client
can recall. Include maternal and paternal
grandparents, aunts and uncles on both
sides, parents, siblings, and the client’s
children. Such thoroughness usually
identifies those diseases that may skip a
generation such as autosomal recessive
disorders. Include the client’s spouse but
indicate that there is no genetic link.
Identifying the spouse’s health problems
could explain disorders in the client’s
children not indicated in the client’s
family history.
SOCIO-CULTURAL HISTORY /
MEDICATIONS
• Questions about social activities help the
nurse to discover what outlets the client
has for support and relaxation and if the
client is involved in the community
beyond family and work.
• Information in this area also helps to
determine the client’s current level of
social development.
• The information gathered about
medication and substance use provides
the nurse with information concerning
lifestyle and a client’s self-care ability.
Medication and substance use can affect
the client’s health and cause loss of
function or impaired senses. In addition,
certain medications and substances can
increase the client’s risk for disease.
ENVIRONMENTAL HISTORY
• Ask questions regarding the client’s
environment to assess health hazards
unique to the client’s living situation and
lifestyle. Look for physical, chemical, or
psychological situations that may put the
client at risk. These may be found in the
client’s neighborhood, home, work, or
recreational environment. They may be
controllable or uncontrollable.
OBSTETRICAL HISTORY (For OB-Gyne
Cases)
• Pre-partum
Age of Menarche ____ Menstrual Cycle
(days)___ Duration of menstruation __
Interval of menstruation__ Number of
pads used during menstruation______
• Intra-partum
Gravity/Parity ____ Type of delivery
AOG___ Fundic Height___
Contractions
(Duration/Interval/Frequency_______
Fetal Heart Rate ____ Fetal Position
____ Fetal
Presentation____________
• Post-partum
Gravity/Parity________ Type of
Delivery_______
Lochia __________ Type of
Episiotomy ___________________