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Obtaining the History -- Subjective data (Past History (Surgeries (Type,…
Obtaining the History -- Subjective data
Biological Data
Name, address, phone number. Age, birth date, birthplace. Marital status. Race, ethnic origin. Occupation (previous & present). Language & communication needs. Education level. Who lives with the client & identify significant others
Reasons for Seeking Healthcare
One or two symptoms or signs and their duration
chief complaint / presenting problem
History of Presenting Illness
detailed information about the problem and how it affects lifestyle and ADL’s
Symptom Analysis (COLDSPAA)
Present Health Status
Health Conditions
Diabetes, hypertension, heart disease, sickle cell anaemia, cancer, seizure disorders, arthritis, mental illness
Medication
Prescription and over the counter, herbal & home remedies
Reason for taking the medication, how long the client has been taking the medication, dose & frequency, side effects, client’s perception of how effective the medication is
Allergies
Food, medications, environmental factors
Elicit nature of allergy
Side effect
Past History
Childhood illnesses
Surgeries
Type, date, outcome
Hospitalisations
Illness, dates, outcome
Immunisations
Last examinations
Accidents or illnesses
Type, dates, outcome
Obstetric history
The Family History
Age & health /death of blood relatives
Specifically enquire about family history of
Heart disease. High blood pressure. Stroke. Diabetes. Blood disorders. Cancer. Arthritis. Allergies. Obesity
Lifestyles & Health Practices Profile
Description of typical day. Nutritional & weight management. Activity level & exercise. Values & belief systems. Education & employment. Stress & coping styles
Sleep & rest. Substance use. Self concept and self care responsibilities. Social activities. Relationships. Environment. Overseas travel
Systems Review for Current Health Problem
To evaluate the past and present health state of each body system
To double check in case significant data was omitted in the present illness section
To evaluate health promotion practices
General Overall Health
State. Pain. General fatigue. Weakness. Fever. Problems with sleep. Unexplained changes in weight
head to toe examination
client asked specific question to draw out
previous or present health concerns
record the presence or the absence or all symptoms
Subjective data only.