NURSING HEALTH HISTORY

Vital Information
Code Name:
Age:
Gender:
Civil Status:
Date of Birth:
Place of Birth:
Race:
Cultural or Ethnic Background/Group:
Primary Language (Spoken and Read):
Secondary Language (Spoken and Read):
Religion (including religious or spiritual practices):
Highest Educational Attainment (Client):
Highest Educational Attainment (Partner/Spouse):
Occupation (Client):
Occupation (Partner/Spouse):
Usual Health Care Provider/s:
Date of Admission:
Date of Discharge:
Source/s of History: (client, SO, chart, attending physician)
Reason/s for Seeking Health Care: (Major health problem or concern; feelings about seeking
health care including fears and past experiences)
Primary Attending Physician:
Consultants/Specialists:
Initial Impression/Diagnosis:
Final Diagnosis:
History of Present Health Concern (COLDSPA)narrative form
Character (Describe the sign or symptom. How does it feel, look, smell, sound, etc?)
Onset (When did it begin; is it better, worse, or the same since it began?)
Location (Where is it? Does it radiate? Does it occur anywhere else?)
Duration (How long does it last? Does it recur?)
Severity (How bad is it on a scale of 1 (barely noticeable) to 10 (worst pain ever experienced?)
Pattern (What makes it bettter? What makes it worse?)
Associated factors (What other symptoms occur with it? How does it affect you? What do you
think caused it to start? Do you have any other problems that seem related to what you are
suffering now?)
Will you be able to continue doing your work or other activities (leisure or exercise)?

Past Health History

Problems at birth
Childhood illnesses
Immunizations to date
Adult illnesses (physical, emotional, mental) – including hospitalizations, current medication,
and other examinations done (PE, dental, vision, hearing, ECG, chest X-ray, Pap smear,
mammogram, etc.
Surgeries
Accidents/Injuries
Prolonged pain or pain patterns
Allergies
Physical, emotional, social, or spiritual weaknesses
Physical, emotional, social, or spiritual strengths
Recent travel (travel within past year especially with travel to endemic and pandemic places)

Obstetric/Gynecologic Histories (when necessary)

Family Health History (Genogram only)

Note: Your genogram is Figure 1 to be included in your List of Figures
 GENOGRAM DIAGRAM

Figure 1. Genogram Showing the Family History of Client X (bold)

Physical Examination and Review of Systems (PEROS)

Notes:
a. Refer also to the old format for specific areas to be examined/assessed.
b. This should be included in your List of Tables
Table 1
Physical Examination and Review of Systems of Client X
Areas Examined Subjective Objective Problems
Findings Findings Identified
1. General Health Survey
a. Physical development
and body build
b. Gender and sexual
c. development
d. Apparent age as
compared to reported
age
e. Skin condition and
color
f. Dress and hygiene
g. Posture and gait
h. Level of consciousness
i. Behaviors, body
movements, and affect
j. Facial expression
k. Speech
l. Vital signs

Note: Your observations should

be written under the objective
findings
2. Integumentary System IPPA
3. HEENT
a. Head and face
b. Eyes
c. Ears
 d. Nose
e. Oral cavity
4. Neck
5. Respiratory System
6. Cardiovascular System
7. Breast and Axilla
8. Gastrointestinal System and
Abdomen
9. Genitourinary/Reproductive
Tract
10. Musculoskeletal System
11. Neurologic System
12. Lymphatic/Hematologic
System
13. Endocrine System

Gordon’s Functional Health Patterns Assessment

Notes:
a. Refer to your old format for specific questions to be asked.
b. This table should be included in your List of Tables.

Table 2
Gordon’s Functional Health Patterns Assessment of Client X
Health Patterns Before Hospitalization During Hospitalization
1. Health Perception and
Health Management
Pattern
2. Nutrition and
Metabolism Pattern
3. Nutrition and
Metabolism Pattern
4. Elimination Pattern
5. Activity and Exercise
Pattern
6. Cognition and
Perception Pattern
7. Sleep and Rest Pattern
8. Self-Perception and
Self-Concept Pattern
 9. Roles and
Relationships Pattern
10. Sexuality and
Reproduction Pattern
11. Coping and Stress
Tolerance Pattern
12. Values and Belief
Pattern

Developmental Level
Note: Description of the developmental level of your client based on the Psychosocial
Development Theory of Erik Erikson
Psychosocial Development (Erik Erikson):