📖 The Complete Health History

🌟 Overview

• The complete health history = foundation of assessment.
• Combines Subjective + Objective data → Database.
• Purpose: Build rapport, gather data, guide diagnosis, promote health.

📝 Health History Structure

Order to Follow

1. Biographic Data
2. Reason for Seeking Care

1. Present Health/HPI
2. Past Health
3. Medication reconciliation

1. Family History

1. Review of Systems (ROS)
2. Functional Assessment (ADLs/IADLs)

👤 Who

• Biographic Data: Name, age, gender/pronouns, language, occupation, marital/relationship, race/ethnicity, interpreter use.
• Source of History: Who provides info, reliability, patient’s condition.
• Many immigrants have significant health care needs (e.g., diabetes, accidents on the job, muscle pain) but are in the country without documentation. They may be reluctant to seek care and furnish biographic data for fear of deportation.

❓ Why

• Reason for Seeking Care: Chief complaint in patient’s words (“chest pain for 2 hours”).

📖 What – Part 1 (History)

• Present Health/HPI: Story of current illness, symptoms.
• Past Health: Illnesses, surgeries, immunizations, allergies, meds.
• Medication reconciliation: the process of creating and maintaining an accurate list of a patient's current medications by comparing the patient's external medication list with their medical record and orders.
• A person could take furosemide from one prescriber and Lasix from another, not knowing that it is the same medication.
• Family History: Genetic risks, hereditary conditions.

🔍 What – Part 2 (Assessment)

• Review of Systems (ROS): Head-to-toe symptom checklist.
• Functional Assessment (ADLs/IADLs): Daily life, coping, supports, risks.

1. 📖 Purpose of Health History

• Well patient: Lifestyle, risk reduction, prevention.
• Ill patient: Chronological story of symptoms.
• All patients: Screen abnormalities, clarify concerns, note coping strategies.

2. 👤 Components of Adult Health History

Eight Critical Symptom Characteristics

1. 📍 Location → Site, localized or radiating.
2. 🎨 Character/Quality → Sharp, burning, throbbing.
3. 🔢 Quantity/Severity → Impact on life, pain scale 0–10.
4. ⏱️ Timing → Onset, duration, frequency, pattern.
5. 🏞️ Setting → Situation when it started.
6. ⚡ Aggravating/Relieving Factors → Triggers & treatments.
7. ➕ Associated Factors → Related symptoms, med effects.
8. 💭 Patient’s Perception → Meaning, fears, concerns.

📜 PQRSTU Mnemonic (Dragonborn Shortcut):

• P – Provokes/Palliates → What angers/calms the dragon?
• Q – Quality/Quantity → What type of fire, how strong?
• R – Region/Radiation → Where does fire spread?
• S – Severity → How deadly (0–10 rune scale)?
• T – Timing → When does it appear?
• U – Understanding → How does the hero see it?

3. 🧩 Functional Assessment (ADLs & IADLs)

• Basic ADLs: Bathing, dressing, toileting, eating, mobility.
• Instrumental ADLs (IADLs): Driving, shopping, cooking, cleaning, using phone, meds, finances.
• Other Areas:
• 🏃 Exercise, sleep, nutrition
• 👨‍👩‍👧 Relationships/supports
• ✝️ Spirituality (FICA: Faith, Influence, Community, Address)
• 😰 Coping & stress
• 🚬 Substance use (Tobacco, Alcohol [CAGE], drugs)
• 🏚️ Environmental hazards (home/work safety)
• 💔 Intimate partner violence (screen directly)
• 💼 Occupational health (hazards, protections, satisfaction)

4. 👶 Special Populations

Children

• Collect: Perinatal history, growth, milestones, immunizations, family dynamics.
• Developmental screening (e.g., autism spectrum disorder).
• Use caregiver insight for accuracy.

🛡️ HEEADSSS for Adolescents

1. 🏠 Home
2. 📚 Education/Employment
3. 🍎 Eating/Body Image
4. ⚔️ Activities/Friends
5. 🍷 Drugs/Alcohol/Tobacco/Vaping
6. ❤️ Sexuality/Relationships
7. ☠️ Suicide/Depression
8. 🛡️ Safety

5. 🧬 Genetic & Environmental Considerations

• At-home genetic tests: Limited accuracy → need follow-up.
• Clinical testing: Reliable, linked to family history & counseling.
• Environment: Consider occupational hazards, toxins, lifestyle.

✅ Key Takeaways

• Health history = clinical tool + therapeutic process.
• Guides: diagnosis, risk ID, prevention, health promotion.
• Requires accurate + empathetic communication.
• Ensures:
• 🤝 Trusting relationship
• 📊 Reliable data
• ⚡ Early detection & prevention

Extra notes: