SIMMONS COLLEGE
GRADUATE PROGRAM IN PRIMARY HEALTH CARE NURSING
Theory and Practice: Primary Health Care Nursing I
The Health History
Biographical Information Full Name: | | | Address: | | | Birthdate: | | | Sex: | | | Race: | | | Marital Status: | | | Next of kin I contact person: | | | Employer I job description: | | | |
Health Care Profile Usual source of health care (provider/facility): | | Medications (Prescription and OTC): | | Allergies (food, drug, environmental): | |
Chief Complaint or Reason for Contact
(current symptoms or follow-up for chronic illness)
History of Present Illness (HPI)
Symptom analysis of all current symptoms and chronology and present status of all
Ongoing chronic illnesses:
If patient presents with a symptom, use symptom analysis (see next page) to elicit the details of the health history.
I f patient presents for follow up of a chronic illness, ask about chronology, present status (see next page).
SIMMONS COLLEGE
GRADUATE PROGRAM IN PRIMARY HEALTH CARE NURSING
Theory and Practice: Primary Health Care Nursing I The Health History
Symptom Analysis Format
1. Onset
a. Date of onset
b. Manner of onset (gradual or sudden) c. Precipitating and predisposing factors related to onset
2. Characteristics
a. Character (quality, quantity, consistency, or other) b. Location and radiation (of pain) c. Intensity or severity
d. Timing (continuous or intermittent, duration of each, temporal relationship to other events)
c. Aggravating or alleviating factors f. Associated symptoms
3. Course since onset
a. Incidence
1. Single acute attack 2 Recurrent acute attacks
3. Daily occurrences 4. Periodic occurrences
5. Continuous chronic episode
b. Progress (better, worse, unchanged)
