The Complete Health HistoryThe Health History: AdultThe Health History: Adult (cont.)Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Developmental CareDevelopmental Care (cont.)Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. The Complete Health HistoryThe Complete Health HistoryChapter 4Chapter 4Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 4: The Complete Health HistoryChapter 4: The Complete Health HistoryThe Health History: AdultThe Health History: Adult1.1.Biographical dataBiographical data2.2.Source of historySource of history3.3.Reason for seeking careReason for seeking care4.4.Present health or history of present illnessPresent health or history of present illness5.5.Past healthPast health6.6.Family historyFamily history7.7.Review of systemsReview of systems8.8.Functional assessment including activities of Functional assessment including activities of daily living (ADLs)daily living (ADLs)Slide 4-2Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 4: The Complete Health HistoryChapter 4: The Complete Health HistoryThe Health History: Adult (cont.)The Health History: Adult (cont.)Biographical dataBiographical dataNameNameAddress and phone numberAddress and phone numberAge and birth dateAge and birth dateBirthplaceBirthplaceSexSexMarital statusMarital statusRaceRaceEthnic originEthnic originOccupation: usual and presentOccupation: usual and presentSlide 4-3Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 4: The Complete Health HistoryChapter 4: The Complete Health HistoryThe Health History: Adult (cont.)The Health History: Adult (cont.)It may be helpful to organize same question It may be helpful to organize same question sequence into a mnemonic, PQRSTU, to help sequence into a mnemonic, PQRSTU, to help remember all pointsremember all pointsP = Provocative or palliativeP = Provocative or palliativeQ = Quality or quantityQ = Quality or quantityR = Region or radiationR = Region or radiationS = Severity scale: 1 to 10S = Severity scale: 1 to 10T = Timing or onsetT = Timing or onsetU = Understand patient’s perception of problemU = Understand patient’s perception of problemSlide 4-4Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 4: The Complete Health HistoryChapter 4: The Complete Health HistoryThe Health HistoryThe Health History: : Adult (cont.)Adult (cont.)Past HealthPast HealthChildhood illnessesChildhood illnessesAccidents or injuriesAccidents or injuriesSerious or chronic Serious or chronic illnessesillnessesHospitalizationsHospitalizationsOperationsOperationsObstetric historyObstetric historyImmunizationsImmunizationsLast examination dateLast examination dateAllergiesAllergiesCurrent medicationsCurrent medicationsSlide 4-5Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 4: The Complete Health HistoryChapter 4: The Complete Health HistoryThe Health History: Adult (cont.)The Health History: Adult (cont.)Family historyFamily historyAge and health or cause of death of relativesAge and health or cause of death of relativesHealth of close family members Health of close family members Family history of various conditions such as heart Family history of various conditions such as heart disease, high blood pressure, stroke, diabetes, disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle-cell anemia, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, and illness, seizure disorder, kidney disease, and tuberculosistuberculosisFamily tree (genogram) to show this information Family tree (genogram) to show this information clearly and conciselyclearly and conciselySlide 4-6Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 4: The Complete Health HistoryChapter 4: The Complete Health HistoryThe Health History: Adult (cont.)The Health History: Adult (cont.)Family tree Family tree or genogramor genogramSlide 4-7Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 4: The Complete Health HistoryChapter 4: The Complete Health HistoryThe Health History: Adult (cont.)The Health History: Adult (cont.)Cross-cultural careCross-cultural careAdditional questions for new immigrantsAdditional questions for new immigrants•Biographical dataBiographical data•Spiritual resource and religion: assess if certain Spiritual resource and religion: assess if certain procedures cannot be doneprocedures cannot be done•Past health: what immunizations, if anyPast health: what immunizations, if any•Health perceptionHealth perceptionHow does person describe health and illnessHow does person describe health and illnessHow does person see problems he or she is now How does person see problems he or she is now experiencingexperiencing•Nutrition: taboo foods or food combinationsNutrition: taboo foods or food combinationsSlide 4-8Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 4: The Complete Health HistoryChapter 4: The Complete Health HistoryThe Health History: Adult (cont.)The Health History: Adult (cont.)Review of systemsReview of systemsGeneral overall health General overall health statestateSkinSkinHairHairHeadHeadEyesEyesEarsEarsNose and SinusesNose and SinusesMouth and ThroatMouth and ThroatNeckNeckBreastBreastAxillaAxillaRespiratory systemRespiratory systemCardiovascularCardiovascularPeripheral vascularPeripheral vascularGastrointestinalGastrointestinalUrinary systemUrinary systemSlide 4-9Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 4: The Complete Health HistoryChapter 4: The Complete Health HistoryThe