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Assistance with completing a Health History Form

Health History Form

Name Date

Directions Using the Health History Guidelines and Rubric complete the chart below with your participant. Please review the rubric prior to gathering your data to assure proper completion of the assignment.

CriteriaData
BIOGRAPHICAL DATA
Date
Initials
Age
Date of birth
Birthplace
Gender
Marital status
Race
Religion
Occupation
Reliability of source of information
PRESENT HEALTH HISTORY/ILLNESS
When do they seek care
Current health status
Health goals
HEALTH BELIEFS AND PRACTICES
Beliefs and practices (exercise patterns, alcohol/drug use, how do they get to work, do they wear a seat belt)
Factors influencing healthcare decisions
MEDICATIONS
Prescription medications
Over-the-counter medications
Herbals
PAST HISTORY
Childhood diseases
Immunizations
Allergies
Major illnesses
Injuries
Hospitalizations
Pregnancies and deliveries
Surgeries
EMOTIONAL HISTORY
emotional psychiatric or substance use related problems
FAMILY HISTORY
Father
Mother
Siblings
Grandparents
PSYCHOSOCIAL/ OCCUPATIONAL HISTORY
Support systems
Occupational history
Educational level
Is money a source of concern
ROLES AND RELATIONSHIPS
Participant’s roles and relationships
Community based activities
ETHNICITY AND CULTURE
Ethnicity and culture
Social traits that influence healthcare decisions
SPIRITUALITY
Religious and spiritual needs
SELF-CONCEPT
View of self-worth (who and what they are)
Future goals
REVIEW OF SYSTEMS (Please refer to your assignment guidelines. This is NOT a physical assessment.)
Skin, hair, nails
Head, neck, related lymphatics
Eyes
Ears, nose, mouth, and throat
Respiratory
Breasts and axillae
Cardiovascular
Peripheral vascular
Abdomen
Endocrine
Urinary
Reproductive
Musculoskeletal
Neurologic

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