Health History

Biographical Data
(name, address and phone number; age and birthday; birthplace; gender; marital status;
race; ethnic origin, occupation – both usual and present)

Source of History
(WHO: patient, parent, spouse, partner; RELIABILITY)

Reason for Seeking Care

(patient’s own words, in quotes)

Present Health or History of Present Illness (OLDCARTS)

O: Onset: When did the problem first start? Setting and circumstances - chronologic sequence of events. Manner of
onset (Sudden vrs. Gradual) What was the person doing? What seems to bring on the symptoms?)

L: Location: Where is it? Exact location, localized or general, radiation patterns.

D: Duration: How long does the problem last? Is it intermittent? Is it constant? What is the duration of each
episode?
C: Character: nature of symptom. Describe the sign or symptom. How does it feel (sharp, dull, aching, throbbing),
how does it look (shiny, bumpy, red, swollen, bruised), how does it sound (loud, soft, rasping), how does it smell
(foul, sweet, pungent ), how intense or severe is it, how much ?
A: Aggravating Factors: Food, activity, rest, certain movements, nausea, vomiting, diarrhea, chills, etc
R: Relieving factors: Prescribed or self medicating therapies; Alternative or complimentary therapies; their effect
on the problem
T: Temporal factors: Frequency; relation to other symptoms, problems, functions, symptom improving or
worsening over time
S: Severity: How bad is it? (on a scale of 1 – 10) Is it getting better, worse, staying the same? effects on ADL’s
and patient’s lifestyle– cannot go to work);

Past Health History

(childhood illness, accidents/injuries/disabilities, serious/chronic illness, hospitalizations,
surgeries,
obstetric history, immunizations, transfusions, last examination (date, what for), allergies (include drugs as
well as environmental) and type of reaction, current medications with dose and frequency – both prescribed
and OTC)

Family Health History

Age and health of blood relatives (parents, grandparents, siblings), or age and cause of
death of blood relatives (parents, grandparents, siblings). Age and health of spouse and
children. Family history of heart disease, high blood pressure, stroke, diabetes, blood
disorders, cancer, sickle cell anemia, arthritis, allergies, obesity, alcoholism, mental
illness, seizure disorder, kidney disease, tuberculosis. Construct a genogram or family
tree to show the information gathered.)

Cross Cultural Care

 When person entered country, circumstances in previous country(refugee, torture issues); identify any
particular spiritual resources or religious practices that would have an impact on health or health
practice(administration of blood etc.); past health r/t immunizations; health perception – individuals
description of health and illness and current problem; nutritional considerations that might be taboo

Health History continued

Review of Systems

Overall Health State:

Describe any recent weight changes such as gain or loss(time frame and manner) , any fatigue, weakness or
malaise; any fever or chills, any sweats or night sweats)

Skin, Hair, Nails: Yes No

Skin:
History of skin disease ____ ____
(eczema, psoriasis, hives)
Pigment or colour change ____ ____
Change in Mole ____ ____
Excessive dryness ____ ____
Excessive moisture ____ ____
Pruritis ____ ____
Excessive Bruising ____ ____
Rash ____ ____
Lesion ____ ____
Health Promotion: (sun exposure, self care for skin)
Hair: Yes No
Recent loss ____ ____
Change in texture ____ ____
Health Promotion: (self care for hair)

Nails:
Change in shape, colour or brittleness ____ ____

Health Promotion: (self care for nails)

Head and Neck: Yes No

Head:
Unusually frequent or severe headache ____ ____
Any head injury ____ ____
Any dizziness(syncope) ____ ____
Any vertigo ____ ____

Neck:
Any Pain ____ ____
Any limitation of motion ____ ____
Any lumps or swelling ____ ____
Any enlarged or tender nodes ____ ____
Any goiter ____ ____

Eyes and Ears:

Eyes:
Difficulty with vision ____ ____
(decreased acuity, blurring, blind spots)
Any eye pain ____ ____
Diplopia or double vision ____ ____
Any redness or swelling ____ ____
Any watering or discharge ____ ____
Glaucoma ____ ____
Cataracts ____ ____
Health promotion: Wearing of glasses or contacts; last vision check or glaucoma check, how is individual coping
with any vision loss?
Ears: Yes No
Earaches ____ ____
Infections ____ ____
Discharge ____ ____
Tinnitus ____ ____
Vertigo ____ ____

Health promotion: Hearing loss(how loss affects daily life, hearing aid use), exposure to environmental noise,
method of cleaning ears)

Nose, Sinuses, Mouth and Throat:

Nose and Sinuses: Yes No

Discharge and characteristics _____ ____
Frequent or severe colds _____ _____
Sinus Pain _____ _____
Nasal Obstruction _____ _____
Nosebleeds _____ _____
Allergies or Hay Fever _____ _____
Change in Sense of Smell _____ _____

Mouth and Throat:

Mouth Pain _____ _____
Frequent sore throat _____ _____
Bleeding Gums _____ _____
Toothache _____ _____
Lesion in mouth or tongue _____ _____
Dysphagia _____ _____
Hoarseness _____ _____
Voice Change _____ _____
Altered taste _____ _____
History of tonsillectomy _____ _____

Health Promotion: pattern of daily dental care; use of prostheses (dentures, bridge), and last dental checkup.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________

Respiratory System: Yes No

History of:
Asthma _____ _____
Emphysema _____ _____
Bronchitis _____ _____
Pneumonia _____ _____
Tuberculosis _____ _____
Any chest pain with breathing _____ _____
Wheezing or noisy breathing _____ _____
Shortness of breath _____ _____
How much activity produces shortness of breath?
____________________________________________________________________________________
_____________________________________________________________________________________
Cough _____ _____
Sputum (Colour, Amount)
______________________________________________________________________________________

______________________________________________________________________________________
Hemoptysis _____ _____
Toxin or Pollution Exposure _____ _____

Health Promotion: Last chest x-ray study? Smoking history?

______________________________________________________________________________________

Cardiovascular System:

Precordial or retrosternal pain _____ _____

Palpitation _____ _____
Cyanosis _____ _____
Dyspnea on exertion _____ _____
If yes, specify amount of exertion
_______________________________

Orthopnea _____ _____

Paroxysmal nocturnal dyspnea _____ _____
Nocturia _____ _____
Edema _____ _____
History of heart murmer _____ _____
Hypertension _____ _____
Coronary Heart Disease _____ _____
Anemia _____ _____
Health Promotion: date of last ECG or other heart tests
______________________________________________________________________________________

Peripheral Vascular:

Any coldness, numbness or tingling _____ _____

Any swelling of legs; (Time of day, activity) _____ _____
______________________________________________________________________________________
Discolouration in hands or feet (bluish red, mottling) _____ _____
Varicose veins _____ _____
Thrombophlebitis _____ _____
Ulcers _____ _____
Intermittant claudication _____ ____

Health Promotion:
Does work involve long term sitting, standing? Wearing of support hose? Avoiding crossing of legs?
______________________________________________________________________________________

Gastrointestinal System: Yes No

Changes/problems with appetite _____ _____

Food intolerance _____ _____
Dysphagia _____ _____
Heartburn _____ _____
Indigestion _____ _____
Pain associated with eating _____ _____
Other abdominal pain _____ _____
Pyrosis _____ _____
(esophageal and stomach burning sensation with sour eructation)
Nausea and vomiting (character) _____ _____
_____________________________________________________

Vomiting blood _____ _____

History of:
Ulcer _____ _____
Liver Disease _____ _____
Gallbladder Disease _____ _____
Jaundice _____ _____
Appendicitis _____ _____
Colitis _____ _____
Any flatulence _____ _____
Frequency of bowel movements and any recent change
___________________________________________________________

Stool characteristics
____________________________________________________________

Constipation _____ _____

Diarrhea _____ _____
Black stools _____ _____
Rectal Bleeding _____ _____
Hemorrhoids _____ _____
Fistula _____ _____

Health Promotion: Use of antacids or laxatives

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Urinary System: Yes No

Frequency or urgency _____ _____
Nocturia (recent change) _____ _____
Dysuria _____ _____
Polyuria _____ _____
Oliguria _____ _____
Hesitancy or Straining _____ _____
Narrowed stream _____ _____
Cloudiness or Presence of Blood _____ _____
Yes No
Urine colour ________________________________
Incontinence _____ _____
Hisory of:
Kidney disease _____ _____
Kidney stones _____ _____
Urinary Tract Infections _____ _____
Prostate Disease _____ _____
Pain in flank, groin or suprapubic region, low back _____ _____

Health Promotion: measures to avoid or treat urinary tract infections, use of Kegel exercises
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________

Male Genital System/Female Genital System:

Male:
Penile or testicular pain _____ _____
Sores or lesions _____ _____
Penile discharge _____ _____
Lumps _____ _____
Hernia _____ _____

Health Promotion: perform testicular self-examination? How frequently?

_____________________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________

Female:
Menstrual history
Age of menarche _____________________
Last menstrual period, cycle and duration _________________________________________

____________________________________________________________________________________
Amenorrhea _____ _____
Menorrhagia _____ _____
Premenstrual pain or dysmenorrhea _____ _____

Yes No
Intermenstrual spotting _____ _____
Vaginal itching _____ _____
Vaginal discharge _____ _____
Characteristics of vaginal discharge _________________________________________________
Age at menopause ___________________________

Menopausal signs or symptoms

_____________________________________________________________________________________________
_______________________________________________________________________________
Postmenopausal bleeding _____ ______

Health Promotion: last gynecologic checkup and last Papanicoloaou test

_____________________________________________________________________________________________
_______________________________________________________________________________

Breast and Axilla: Yes No

Any breast pain? _____ _____

Any evidence of a lump? _____ _____
Any nipple discharge? _____ _____
Any rash? _____ _____
History of breast disease? _____ _____
Surgery on the breasts? _____ _____
Any swelling under the arms? _____ _____

Health Promotion:

Performs breast self exam; include frequency and method used. Date of last mammogram.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________________________________________

Sexual History:

Current sexual activity____________________________________________________________________

Protective measures___________________________________________________________________

Level of sexual satisfaction of patient and partner_______________________________________

Dyspareunia (for female) ______ ______

Changes in erection or ejaculation (for male) ______ ______

Any known or suspected contact with a partner who has a sexually transmitted disease(gonorrhea, herpes,
chlamydia, venereal warts, AIDS or syphilis) ______ ______

Musculoskeletal System: Yes No

History of arthritis _____ _____

History of gout _____ _____
History of back pain or disc disease _____ _____
Joint pain _____ _____
Stiffness _____ _____
Swelling _____ _____
Deformity _____ _____
Limitation of motion _____ _____
Noise with joint motion _____ _____
Muscle pain _____ _____
Muscle cramps _____ _____
Weakness _____ _____
Gait problems _____ _____
Problems with coordinated activities _____ _____

Health Promotion: How much walking per day? What is effect of limited range of motion on ADL’s such as
grooming, feeding, toileting, dressing? Any mobility aids used?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________________________________________

Neurologic System Yes No

History of seizure disorder _____ _____

History of stroke _____ _____
History of fainting or blackouts _____ _____

Motor function:
Any weakness, tic or tremor _____ _____
Any paralysis or coordination problems _____ _____

Sensory function:
Any numbness and tingling(parathesia) _____ _____

Cognitive function:
Any recent memory disorder _____ _____
Any disorientation _____ _____

Mental Status:
Nervousness _____ _____
Mood change _____ _____
Depression _____ _____
History of mental health dysfunction or hallucinations _____ _____
Describe:_______________________________________________________________________
_____________________________________________________________________________
____________________________________________________________

Hematologic System: Yes No

Any bleeding of skin or mucous membranes _____ _____

Any excessive bruising _____ _____

Any swelling of lymph nodes _____ _____

Any exposure to toxic agents or radiation _____ _____
Any blood transfusions or reactions _____ _____

Endocrine System:

Any history of diabetes or diabetic symptoms _____ _____

(polyuria, polydipsia, polyphagia)
History of thyroid disease _____ _____
Intolerance to heat or cold _____ _____
Change in skin texture or pigmentation _____ _____
Excessive sweating _____ _____
Abnormal hair distribution _____ _____
Any nervousness _____ _____
Tremor _____ _____
Need for hormone replacement _____ _____
Any change in relationship between appetite and weight _____ _____

Health History (continued)

Personal/ Social History: Information regarding concerns of patient

and influence of health problems on patient’s and family’s life
Cultural background and practices:
Birthplace
 Position in family, Marital status (Social roles: Role in the family? How do you get
along with family, friends, and coworkers: Support systems: Who do you go to for
support for problems in family, at work, with your health, or with a personal problem?
Amount of contact with spouse, siblings, parents, children, friends, organizations,
workplace? Is time alone enjoyable or isolating?)

Religious preferences (Faith: Does religious faith or spirituality play an important role
in your life?
Influence: How does your religious faith or spirituality influence the way you think
about your health or way you care for yourself?
Community: Are you a part of any religious or spiritual community or congregation?
Address: Would you like me (the health care professional) to address any religious or
spiritual issues or concerns with you?)

Self-Esteem, Self-Concept
General life satisfaction, hobbies, interests
Education: last grade completed, other significant training;
Financial status: income adequate for lifestyle and/or health concerns;
Value-belief system: religious practices and perception of personal strengths)

Personal Habits:
(Tobacco: Do you smoke? cigarettes, pipe, chewing tobacco? At what age did you start?
How many packs per day? How many years? If stopped, how long since stopped and the
same questions asked for the time they were a smoker. If they have tried to quit, what
did they try? How did it go? Which leads into smoking cessation discussion.)

Alcohol: Do you drink alcohol? When was your last drink? How much do you drink each
day, each week? If patient answers ‘no’ to drinking alcohol ask the reason for this
decision. Any history of drinking alcohol? Any history of treatment? Involvement in
recovery activities? History of family member with problem drinking?

Street Drugs: Ask specifically about marijuana, cocaine, crack cocaine, amphetamines,
and barbiturates. Indicate frequency of use and how use has affected work and family.)

Exercise: (Daily profile reflecting usual daily activities, ‘Tell me about a

typical day’, ability to
perform ADLs, IADL’s (independent or needs assistance); ability to tolerate activity;use of
prostheses or mobility aids; leisure activities enjoyed; and exercise pattern (type,
amount per day or week, warm-up session body’s response to exercise))

Sleep/Rest
(Sleep patterns, daytime naps, any sleep aids used)

Nutrition/Elimination
(Record the diet recall for 24-hour period. Is this menu typical? Who buys and prepares
 food? Finances? Who is present at meal times? Food allergy or intolerance. Daily intake
of caffeine (coffee, tea, cola drinks). Usual patterns for bowel elimination and urinating.
Aids used for mobility or transfer in toileting. Any continence issues or use of laxatives.)

Coping and Stress Management

(Kinds of stresses in life, especially in the last year, any change in lifestyle or any current
stress, methods tried to relieve stress and if these have been helpful.)

Environment/Hazards
Home, school, work.(Where do they live? With whom? Do they know their neighbours and the
neighbourhood? Safety of the area? Adequate heat and utilities? Access to
transportation? Involved in the community? Note environmental health, hazards
in the workplace and the home? Use of seat belts? Geographic or occupational
hazards (time spent abroad for travel or work)?)

Intimate Partner Violence

(How are things at home? Do you feel safe? If patient responds to feeling unsafe
then specific questions. Ever been emotionally or physically abused by your
partner or someone important to you? Ever been hit, slapped, kicked, pushed or
shoved or otherwise physically hurt by your partner or ex-partner? Partner ever
forced you into having sex? Are you afraid of your partner or ex-partner?)

Occupational Health
Work conditions and hours. Physical and mental strain; Work with any health
hazards (asbestos, inhalants, chemicals, repetitive motion.) Protective devices used. Any
programs at work designed to monitor your exposure? Any health problems you think are
related to your job? What doyou like or dislike about your job?)

Perception of Own Health

(How do you define health? View of own health now? What are your concerns? What do
you expect will happen to your health future? Your health goals? What expectations do
you have of the health care team?)

Reference
Jarvis, C. (2008). Physical examination and health assessment (5th ed.). Philadelphia:
W.B. Saunders.