I.

Biographical Data

Name: Age:
Address: Birthdate:
Gender:
Provider of History:
Place of Birth:
Race or Ethnic Background:
Primary and Secondary Languages (spoken and read):
Marital Status:
Religious or Spiritual Practices:
Educational Level:
Occupation:
Significant others or Support Persons (availability):

II. Reason for Seeking Health Care

A. Reason for Seeking health care (major health problems)
B. Feelings about seeking health care ( fears and past experiences)
III. History of Present Health Concern (using COLDSPA, PQRST)
A. Character
B. Onset
C. Location
D. Duration
E. Severity
F. Pattern
G. Associated Factors
IV. Past Health History
A. Problems at birth
B. Childhood Illnesses
C. Immunizations to date
D. Adult Illnesses
E. Surgeries
F. Accidents
G. Prolonged pain or pain patterns
H. Allergies
I. Physical, Emotional, Social, or Spiritual Weaknesses
J. Physical, Emotional, Social, or Spiritual Strengths

V. Obstetrical History
VI. Family Health History
 A. Age of Parents
B. Parents Illnesses and Longevity
C. Grandparents illnesses and longevity
D. Aunts and uncles ages and illnesses and longevity
E. Children’s ages and illnesses or handicaps and longevity

VII. Review of System

General Appearance:
Head
Eyes
Ear
Nose
Mouth
Neck
Posterior thorax
Anterior thorax
Heart and Neck Vessels
Abdomen
Hips and Lower Extremities
Ankles and Feet
VIII. Lifestyle and Health Practices
A. Description of a Typical Day
B. Nutrition and Weight Management
C. 24-hour dietary intake
D. Who purchases and prepares meals
E. Activities on a typical day
F. Exercise habits and pattern
G. Sleep and rest pattern
H. Use of medications
I. Self-Concept
J. Self-Care Responsibilities
K. Social Activities for Fun and Relaxation
L. Social Activities contributing to Society
M. Relationships with the family, significant others and pets
N. Values, religious affiliation, spirituality
O. Past, Current, and Future plans for Education
P. Type of Work, level of satisfaction, work stressors
Q. Finances
R. Stressors in life, coping strategies used
S. Residency, type of environment, neighbourhood, environmental risks
IX. Developmental Level