Nursing Health History Format (Used For Client Care Plan)

NURSING HEALTH HISTORY FORMAT (USED FOR CLIENT CARE PLAN)
Biographical Data
Name
Address
Phone
Gender
Provider of history (patient or other)
Birth date
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)
Reasons for Seeking Health Care
Reason for seeking health care (major health problem or concern)

Feelings about seeking health care (fears and past experiences)
History of Present Health Concern Using COLDSPA
Character (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?)
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 better? What makes it worse?)
Associated factors (What other symptoms do you have with it?
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)
Surgeries
Accidents
Prolonged pain or pain patterns
Allergies
Physical, emotional, social, or spiritual weaknesses
Physical, emotional, social, or spiritual strengths
Family Health History

Age of parents (Living? Deceased date?)
Parents’ illnesses and longevity
Grandparents’ illnesses and longevity
Aunts’ and uncles’ age and illnesses and longevity
Children’s ages and illnesses or handicaps and longevity
Review of Systems for Current Health Problems
Skin, hair, and nails: Color, temperature, condition, rashes, lesions,

excessive sweating, hair loss, dandruff
Head and neck: Headache, stiffness, difficulty swallowing, enlarged
lymph nodes, sore throat
Ears: Pain, ringing, buzzing, drainage, difficulty hearing, exposure
to loud noises, dizziness, drainage
Eyes: Pain, infections, impaired vision, redness, tearing, halos,
blurring, black spots, flashes, double vision
Mouth, throat, nose, and sinuses: Mouth pain, sore throat, lesions,
hoarseness, nasal obstruction, sneezing, coughing, snoring,
nosebleeds
Thorax and lungs: Pain, difficulty breathing, shortness of breath
with activities, orthopnea, cough, sputum, hemoptysis,
respiratory infections
Breasts and regional lymphatics: Pain, lumps, discharge from
nipples, dimpling or changes in breast size, swollen and tender
lymph nodes in axilla
Heart and neck vessels: Chest pain or pressure, palpitations,
edema, last blood pressure, last electrocardiogram (ECG)
Peripheral vascular: Leg or feet pain, swelling of feet or legs, sores
on feet or legs, color of feet and legs
Abdomen: Pain, indigestion, difficulty swallowing, nausea and
vomiting. Gas, jaundice, hernias
Male genitalia: Painful urination, frequency or difficulty starting
or maintaining urinary system, blood in urine, sexual problems,
penile lesions, penile pain, scrotal swelling, difficulty with
erection or ejaculation, exposure to STIs
Female genitalia: Pelvic pain, voiding pain, sexual pain, voiding
problems (dribbling, incontinence) age of menarche or
menopause (date of last menstrual period), pregnancies and
types of problems, abortions, STIs, HRT, birth control methods
Anus, rectum, and prostate: Pain, with defecation, hemorrhoids,
bowel habits, constipation, diarrhea, blood in stool
Musculoskeletal: Pain, swelling, red, stiff joints, strength of
extremities, abilities to care for self and work
Neurologic: Mood, behavior, depression, anger, headaches,
concussions, loss of strength or sensation, coordination,
difficulty with speech, memory problems, strange thoughts or
actions, difficulty reading or learning
Lifestyle and Health Practices
Description of a typical day (AM to PM)

Nutrition and weight management
24-hour dietary intake (foods and fluids)
Who purchases and prepares meals
Activities on a typical day
Exercise habits and patterns
Sleep and rest habits and patterns
Use of medications and other substances (caffeine, nicotine,
alcohol, recreational drugs)
Self-concept
Self-care responsibilities
Social activities for fun and relaxation
Social activities contributing to society
Relationships with family, significant others, and pets
Values, religious affiliation, spirituality
Past, current, and future plans for education
Type of work, level of job satisfaction, work stressors
Finances
Stressors in life, coping strategies used
Residency, type of environment, neighborhood, environ mental risks
Developmental Level
Young adult: Intimacy versus isolation
Middlescent: Generativity versus stagnation
Older adult: Ego integrity versus despair

Nursing Health History Format (Used For Client Care Plan)

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Nursing Health History Format (Used For Client Care Plan)

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Nursing Health History Format (Used For Client Care Plan)

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NURSING HEALTH HISTORY FORMAT (USED FOR CLIENT CARE PLAN)

Reason for seeking health care (major health problem or concern)

History of Present Health Concern Using COLDSPA

Character (How does it feel, look, smell, sound, etc.?)

Past Health History

Family Health History

Review of Systems for Current Health Problems

Skin, hair, and nails: Color, temperature, condition, rashes, lesions,

Lifestyle and Health Practices

Description of a typical day (AM to PM)

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