health history form | Nursing homework help

Criteria

Data

BIOGRAPHICAL DATA

Date

Initials

Age

Date of birth

Birthplace

Gender

Marital status

Race

Religion

Occupation

Reliability of source of information

PRESENT HEALTH HISTORY/ILLNESS

When do they seek care

Current health status

Health goals

HEALTH BELIEFS AND PRACTICES

Beliefs and practices (exercise patterns, alcohol/drug use, how do they get to work, do they wear a seat belt)

Factors influencing healthcare decisions

MEDICATIONS

Prescription medications

Over-the-counter medications

Herbals

PAST HISTORY

Childhood diseases

Immunizations

Allergies

Major illnesses

Injuries

Hospitalizations

Pregnancies and deliveries

Surgeries

EMOTIONAL HISTORY

emotional psychiatric or substance use related problems

FAMILY HISTORY

Father

Mother

Siblings

Grandparents

PSYCHOSOCIAL/ OCCUPATIONAL HISTORY

Support systems

Occupational history

Educational level

Is money a source of concern

ROLES AND RELATIONSHIPS

Participant’s roles and relationships

Community based activities

ETHNICITY AND CULTURE

Ethnicity and culture

Social traits that influence healthcare decisions

SPIRITUALITY

Religious and spiritual needs

SELF-CONCEPT

View of self-worth (who and what they are)

Future goals

REVIEW OF SYSTEMS (Please refer to your assignment guidelines. This is
NOT a physical assessment.)

Skin, hair, nails

Head, neck, related lymphatics

Eyes

Ears, nose, mouth, and throat

Respiratory

Breasts and axillae

Cardiovascular

Peripheral vascular

Abdomen

Endocrine

Urinary

Reproductive

Musculoskeletal

Neurologic

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