The Complete Health History

Louise Ma
Mind Map by Louise Ma, updated more than 1 year ago
Louise Ma
Created by Louise Ma over 4 years ago
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Mind Map on The Complete Health History, created by Louise Ma on 02/03/2017.

Resource summary

The Complete Health History
  1. Biographic Data
    1. Name, address, phone number, age, birth date, birthplace, gender, marital partner status, race, ethnic origin, occupation, illness or disability, primary language
      1. source of history
        1. record who gave the information. Judge how reliable the informant and information is
    2. Reason for seeking care
      1. subjective data- symptoms, sign, reason for the visit
      2. Present health or history of present illness
        1. Location of the pain i.e. pain behind the eyes
          1. character or quality- i.e.) descriptive terms such as burning, sharp, dull..
            1. quantity or severity- i.e. pain scale 0-10
              1. timing- onset, duration, frequency
                1. setting- where was the person or what was the person doing when symptom started i.e. chest pain start when shoveling snow?
                  1. Aggravating or Relieving Factors- what makes the pain worse i.e. food, medication
                    1. associated factors- primary symptom associated with other factors?
                      1. patient's perception- how symptoms has affected the patient
        2. past history
          1. residual effects on the current health state. previous illness may also give clues about how the person responds to illness and the significance of the illness
            1. childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalization, operations, obstetric history, immunizations, last examination date, allergies. current medications
          2. family history
            1. family history highlights diseases and conditions for which a particular patient may be at increased risk
              1. pedigree/genogram- graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations
            2. review of systems
              1. 1. to evaluate the past and present health state of each body system 2. double check in case any significant data were omitted in the present illness section 3. evaluate health promotion practices
                1. general overall health state, skin, hair, head, eyes, ears, nose and sinuses, neck, mouth and throat, breast, axilla, respiratory system, cardiovascular, peripheral vascular, gastrointestinal, urinary system, male/female genital system, sexual health, musculoskeletal system, neurological system, hematologic system, endocrine system
              2. functional assessments of activities of daily living (ADLs)
                1. measures a person's self-care ability in the areas of general physical or absence of illness
                  1. self esteem, self concept, activity/exercise, sleep/rest, nutrition/elimination, interpersonal relationships/resources, spiritual resources, coping and stress management, personal habits, alcohol, illicit or street drugs, environment/hazards, intimate partner violence, occupational health
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