CHAPTER-3-THE-COMPREHENSIVE-HEALTH-HISTORY- (1).pptx

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1. THE COMPREHENSIVE HEALTH HISTORY

2. The purpose of health history is to collect subjective data - what the patient says about himself or herself. The history is combined with objective data from the physical examination and laboratory studies to form the data base . Health History

3. The health history provides a comprehensive portrait of the patient's past and present health. The component of a health history are as follows: Biographic Data Reason for Seeking Care (Chief complaint of present illness) Present health or history of present illness Current medication (Medication Reconciliation) Family history Review of systems (ROS) Functional assessment of activities of daily living (ADL's)

4. The Health History - The Adult

5. Biographic Data Name Address and phone number; email address Age and birth date Birthplace Gender Marital Status Race, Ethnic Origin spoken (e.g. speaks Ilocano only, speaks Chinese only).

6. Biographic Data Occupation (usual and present - an illness or disability may have prompted change in occupation) Language and communication needs (primary language and authorized representative should be recorded ; if the patient does not speak English or Filipino/Tagalog, specify the language / dialect Source of History Record who furnishes the information (e.g. the patient, relative or friend).

7. Biographic Data Judge how reliable the information seems and how willing he or she is to communicate. What is reliable? A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. Note any special circumstances, such as the use of an interpreter. Examples: Patient herself, who seems reliable. Patient's son, Joseph Peter, who seems reliable. Mrs. Ling Nam, interpreter for Sun Jing who does not speak Filipino or English (speaks Chinese only).

8. 2. Reason for Seeking Care (Chief Complaint) This is a brief spontaneous statement in the patient's own words that describes the reason for the visit. It states one (possibly two signs or symptoms and their duration. A sign is an abnormality that can be detected on physical examination or in laboratory studies. A symptom is a subjective sensation that the person feels from the disorder.

9. 2. Reason for Seeking Care (Chief Complaint) The chief complaint is enclosed in quotation marks to indicate the person's exact words. This is now replaced with "reason for seeking care" that incorporates wellness needs. "Chest pain for 2 hours." "Earache and fussy all night." "Dizziness and ringing of the right ear" "Need yearly physical examination for work." Examples:

10. 2. Reason for Seeking Care (Chief Complaint) The chief complaint is not a diagnostic statement. Avoid translating it into terms of a medical diagnosis (e.g., "increasing shortness of breath for four hours," not "emphysema").

11. 3. Present Health or History of Present illness For the well person, this is a short statement about general state of health. For the ill person, this is a chronological record of the reason for seeking care, from the time the symptom first started until now. "Please tell me all about your headache, from the time it started until the time you came to the hospital." Examples:

12. 3. Present Health or History of Present illness The final summary of any symptom should include the following eight critical characteristics: a. Location E.g., pain - "pain behind the eyes," "jaw pain." "Is the pain localized to this site, or radiating?" "Is the pain superficial or deep?" b. Quality or Character. This calls for specific descriptive terms such as burning, sharp, dull, aching, gnawing, throbbing, shooting, vise- like.

13. 3. Present Health or History of Present illness c. Quantity or Severity. d.Timing (Onset, Duration, Frequency) . Attempt to quantify the sign and symptom, e.g., "profuse menstrual flow soaking five pads per hour.“ Or using Wongs pain scale 1-10 When did the symptom first appear? Or state specifically how long ago the symptom started prior to arrival. How long did the symptom last? Was it steady (constant) or did it come and go during that time (intermittent)?

14. 3. Present Health or History of Present illness e. Setting. Example: Where was the person or what was the person doing when the symptom started? What brings it on? "Did you notice the chest pain after carrying a heavy lead, or did the pain start by itself?

15. 3. Present Health or History of Present illness f. Aggravating or Relieving Factors. Example: What makes the pain worse? "Is it aggravated by weather, activity, food, medication, time of day, season and so on?" What relieves it (e.g., rest, medication, ice pack)? What is the effect of treatment? Example: "What have you tried?" or "What seems to help?"

16. 3. Present Health or History of Present illness g. Associated Factors. Is the primary symptom associated with any other symptoms (e.g., urinary frequency and burning associated with fever and chills?) Review the body system related to this symptom now rather than wait for the review of systems. h. Patient's Perception. Find out the meaning of the symptom by asking how it affects daily activities. Also ask directly, "What do you think it means?" This is crucial because it alerts the nurse to potential anxiety if the person thinks the symptoms may be ominous.

17. 3. Present Health or History of Present illness To help remember all the points, organize this question sequence into the mnemonic PQRSTU . P : Provocative and Palliative. What brings it on? What were you doing when you first notice it? What makes it better? Worse? Q : Quality or Quantity. How does it look, feel, sound? How intense/severe is it? R : Region or Radiation. Where is it? Does it spread anywhere? S : Severity Scale. How bad is it (on a scale of 1 to 10?) Is it getting better, worse, staying the same?

18. 3. Present Health or History of Present illness T: Timing. Onset - exactly when did it first occur ? Duration - how long did it last? Frequency - how often does it occur? U: Understand Patient's Perception of the Problem. What do you think it means?

19. 4. Past Health History Past health events may have residual effects on the current state of health. Previous experience with illness may give clues on how the patient responds to illness and to the significance of illness for him or her. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep b. Accidents or Injuries . Auto accidents, fractures, head injuries, burns, falls. c. Serious or Chronic Illness . Diabetes, hypertension, heart disease, cancer, seizure disorder.

20. 4. Past Health History d. Hospitalizations . Cause, name of hospital, how the condition was treated, how long the person was hospitalized and name of the physician. e. Operations. Type of surgery, date, name of the surgeon, name of deliveries in which the fetus reached full term, number of preterm pregnancies, number of abortions and number of children living. This is recorded: Gravida, Term, Preterm, Abortion, Living.

21. 4. Past Health History f. Obstetric History . Number of pregnancies (Gravidity), polio, diphtheria - pertussis - tetanus (DPT), hepatitis B, human papilloma virus (HPV), haemophilus influenza type b (Hib), pneumococcal vaccine. Note the date last tetanus immunization, last tuberculosis skin test and last flu shot. g. Last Examination Date : Physical, dental, vision, hearing, electrocardiogram (ECG), chest X-ray examinations.

22. 4. Past Health History h . Allergies . Note both the allergen (medication, food, or contact agent) and the reaction (rash, itching, runny nose, watery eyes, difficulty breathing).

23. 5. Current Medications (Medication Reconciliation) Note all prescription and over the counter (OTC) medications and herbal remedies. Ask specifically for vitamins, birth control pills, aspirin and antacids. For each medication, note the name, dose and schedule and ask, "How often do you take it each day?" What is it for?" and "How long have you been taking it?" Prescribed medications may have adverse interactions with OTC's and herbal medications.

24. 5. Current Medications (Medication Reconciliation) This also ensures evaluation of medications taken by the patient by the physician - either to continue the medication unchanged, to continue but change dose, or to discontinue the medication. Medication reconciliation in a comparison of a list of current medication with a previous list, which is done at every hospitalization and every clinic visit.

25. Ask about the age and health or age and cause of death of blood relatives such as parents, grandparents, siblings. These data may have genetic significance for the patient. Ask about close family members such as spouse and children. If there is prolonged contact with any communicable disease (e.g., husband has pulmonary tuberculosis). 6. Family History

26. Ask family history of heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease and tuberculosis. A pedigree or genogram is the most fruitful way to complete a family history (see Appendix). 6. Family History

27. The order of the examination is from head to toe. Remember, that the health history should be limited to patient statements or subject data --factors that the person says were or were not present. 7. Review of Systems (ROS)

28. General Overall State

29. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep General Overall Health State Present weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats, or night sweats.

30. Skin History of skin disease (eczema, psoriasis), change in pigmentation, texture or color, change in mole, excessive dryness, sweating, pruritus, hair growth and distribution, excessive bruising.

31. Recent loss, change in texture. Nails: change in shape, color or brittleness. Health promotion: amount of sun exposure, method of self-care for skin and hair. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Hair

32. Any unusually frequent or severe headache, any head injury, dizziness, vertigo, syncope. Head

33. Difficulty with vision (decreased activity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling watering or discharge, glaucoma, cataracts, photophobia, itching. Health Promotion: Wears glasses or contracts; last vision checks or glaucoma test; and how is he/she coping with loss of vision if any. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Eyes

34. Eyes

35. Earaches, infections, discharge and its characteristics, tinnitus (ringing of the ears) vertigo (sensation of spinning of the room or selt). Health Promotion: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, and method of cleaning ears. Ears

36. Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in the sense of smell. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Nose and Sinuses

37. Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth and tongue, dysphagia (difficulty in swallowing), hoarseness or voice change, tonsillectomy, altered taste. Health Promotion: Pattern of daily dental care, use of prostheses (dentures, bridge) and last dental check-up. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Mouth and Throat

38. Pain, limitation of motion, lumps or swelling, enlarged or tender modes, goiter. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Neck

39. Pain, lump, nipple discharge, rash, history of breast disease, any surgery on the breasts. Health Promotion: Performs breast self-examination (BSE), including its frequency and method used, last mammogram. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Breast Axilla Tenderness, lump or swelling, rash

40. History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis). Chest pain with breathing Wheezing or noisy breathing Shortness of breath, how much activity produces shortness of breath Cough, sputum (color, amount), hemoptysis (coughing up with blood) Toxin or pollution exposure Health Promotion: Last Chest X-ray study a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Respiratory System

41. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Respiratory System

42. Precordial or retrosternal pain Palpitations Cyanosis (bluish discoloration of the skin) Dyspnea on exertion (e.g, shortness of breath when walking on flight of stairs, walking from chair to bath, or just talking) Orthopnea (difficulty in breathing when lying down, relieved by upright position) Cardiovascular System

43. Paroxysmal nocturnal dyspnea (difficulty in breathing 2 to 5 hours after going to sleep during the night). Nocturia (frequent urination during the night) Edema History of heart murmur Hypertension, coronary artery disease, anemia Health promotion: Date of last ECG or other heart tests a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Cardiovascular System

44. Coldness, numbness and tingling, swelling of legs (time of day, activity). Discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles). Varicose veins or complications. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Peripheral Nervous System

45. Intermittent claudication (leg pain on activity and exercise relieved by rest. Thrombophlebitis, ulcers Health promotion: Does the work involve long-term sitting or standing? Avoid crossing the legs at the knees. Wear support hose. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Peripheral Nervous System

46. Appetite, food intolerance Dysphagia (difficulty in swallowing, heartburn, indigestion, pain associated with eating Abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation) a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Gastrointestinal System

47. Nausea and vomiting, hematemesis (vomiting blood) History of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis) Flatulence, frequency of bowel movement, stool characteristics, constipation or diarrhea, black stools. a. Childhood Illness . Measles, mumps, rubella, chicken pox, pertussis and strep Gastrointestinal System

48. Rectal bleeding, rectal conditions (hemorrhoids, fistula) Health Promotion: Use of antacids or laxatives Gastrointestinal System

49. Frequency, urgency, nocturia Dysuria, polyuria, oliguria Hesitancy or straining, narrowed stream Urine color (cloudy or presence of hematuria) Incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate enlargement) Urinary System

50. Pain in flank, groin, suprapubic region of low back Health Promotion: Measures to avoid or treat urinary tract infections, use of Kegel's exercises after childbirth Urinary System

51. Peni or testicular pain Sores or lesions, penile discharge, lumps, hernia Health Promotion: Perform testicular self-examination? How frequent? Male Genital System

52. Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea, menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting) Vaginal itching, discharge and its characteristics Age at menopause, menopausal signs and symptoms, postmenopausal bleeding Female Genital System Health Promotion: Last gynecologic check-up and last Papanicolaou test

53. Female Genital System

54. History of arthritis or gout In the joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, crepitus, (noise with joint motion) In the muscles: any pain, cramps, weakness, gait problems, problems with coordinated activities. Musculoskeletal System In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, history of back pain or disk disease. Health Promotion: How much walking per day? What is the effect of limited range of motion on daily activities such as grooming, feeding, toileting, dressing? Are any mobility aids used?

55. Musculoskeletal System

56. Musculoskeletal System

57. History of seizure disorder, stroke, fainting blackouts. In motor function: weakness, tic or tremor, paralysis or coordination problems. In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent, distant), disorientation Neurologic System

58. In mental status: any nervousness, mood change, depression, or any history of mental health dysfunction or hallucinations. Health Promotion: Interpersonal relationships and coping patterns. Neurologic System

59. Bleeding tendency of skin or mucous membranes, excessive bruising Lymph node swelling Exposure to toxic agents or radiation Blood transfusion and reactions Hematologic System

60. Hematologic System

61. History or diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia). History of thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy. Endocrine System

62. Endocrine System

63. Functional assessment measures a person's self-care ability in the areas of general physical health or absence of illness. This includes the following: 8. Functional Assessment (Including Activities of Daily Living) Activities of Daily Living (ADL's) E.g., bathing, dressing, toileting, eating, walking Instrumental Activities of Daily Living (IADL's) or those needed for independent living. E.g., housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances.

64. 8. Functional Assessment (Including Activities of Daily Living) 5. Self-Concept and Coping 6. Home Environment Functional Assessment questions which should be included standard health history are as follows: 1. Self-esteem, Self-concept Education attainment and trainings Financial status (income) Religious practices and perception of personal strengths (value - belief system)

65. 8. Functional Assessment (Including Activities of Daily Living) 2. Activity/Exercise Usual daily activities (ask: "Tell me how you spend a typical day?") Ability to perform ADL's: independent or needs assistance with feeding, bathing, hygiene, dressing, toileting, bed to chair transfer, walking, standing, or climbing stairs. Any use of wheelchair, prostheses or mobility aids? Leisure activities enjoyed Exercise pattern (type, amount per day or week, method of monitoring the body's response to exercise)

66. 8. Functional Assessment (Including Activities of Daily Living) 3. Sleep and Rest Sleep patterns Daytime naps Any sleep aids used (sleeping pills, CPAP for sleep apnea/snoring) 4. Nutrition/Elimination Diet recall (24-hour recall) Eating habits and current appetite

67. 8. Functional Assessment (Including Activities of Daily Living) " Who buys food and prepares food?" "Are your finances adequate for food?" "Who is present at mealtimes?" Food allergies and intolerance Daily intake of caffeine (coffee, tea, cola drinks) Usual pattern of bowel with mobility or transfer in toileting, continence, use of laxatives. Ask:

68. 8. Functional Assessment (Including Activities of Daily Living) 5. Interpersonal Relationships Resources Social Roles: "How would you describe your role in the family? "How would you say you get along with the family, friends and, and co-workers?" Support Systems: "To whom could you go for support with a problem at work, with your health, or a personal problem?"

69. 8. Functional Assessment (Including Activities of Daily Living) 6. Spiritual Resources Faith: "Does religious faith or spirituality play an important part in your life?" "Do you consider yourself to be a religious or spiritual person?" Influence: "How does your religious faith or spirituality influence the way you think about your health or the way you care for yourself?"

70. 8. Functional Assessment (Including Activities of Daily Living) Community: "Are you a part of any religious or spiritual comtnunity or congregation?" Address: "Would you like me to address any religious or spiritual issues or concerns with you?"

71. 8. Functional Assessment (Including Activities of Daily Living) 7. Coping and Stress Management Kinds of stresses in life, especially in the last year, any change in lifestyle or any current stress. Methods tried to relieve stress, and if these have been helpful. 8. Personal Habits Tobacco, Alcohol, Street Drugs:

72. 8. Functional Assessment (Including Activities of Daily Living) "Do you smoke cigarettes?" "At what age did you start?" "How many packs do you smoke per day?" "How many years have you smoked?" "Have you ever tried to quit?" "How did it go?" ✔️Tobacco Use

73. 8. Functional Assessment (Including Activities of Daily Living) "Do you drink alcohol?" "When was your last drink of alcohol?" "How much did you drink that time?" "Out of the last 30 days, about how many days would you say that you drink alcohol?" "Have you ever had a drinking problem?" "Do you have a history of alcohol treatment?" "Do you have a history of family member with problem drinking?" ✔️ Alcohol

74. 8. Functional Assessment (Including Activities of Daily Living) CAGE Test (Ewing, 1984) Screening Questionnaire to identify excessive or uncontrolled drinking. C - ut down (Have you ever thought that you should cut down your drinking?) A - nnoyed (Have you ever been annoyed by criticism of your drinking?'") G -uilty (Have you ever felt guilty about your drinking?") E - ye Opener (Do you drink in the morning?)

75. 8. Functional Assessment (Including Activities of Daily Living) If the person answers "yes" to two or more CAGE questions, suspect alcohol abuse. If the person answers "no" to drinking alcohol, ask the reason for this decision (e.g., psychosocial, legal, health, religion). ✔️illicit / Street Drugs (Exercise great caution when asking question about use of drugs) ✔️Ask specifically about marijuana, cocaine, amphetamines, and barbiturates. Frequency of use and how has usage affected work or family.

76. 8. Functional Assessment (Including Activities of Daily Living) 9. Environment Hazards Safety of area Adequate ventilation and utilities Access to transportation Involvement in community services Hazards in workplace, at home Housing and neighborhood

77. 8. Functional Assessment (Including Activities of Daily Living) 10.Intimate Pattern: Violence Ask: Begin with open - ended questions. "How are things at home?" "Do you feel safe?" These are valuable initial questions, because some people may not recognize that they are in abusive situations or may be reluctant to admit it due to guilt , fear , shame or denial .

78. 8. Functional Assessment (Including Activities of Daily Living) 10.Intimate Pattern: Violence Ask: Begin with open - ended questions. "How are things at home?" "Do you feel safe?" These are valuable initial questions, because some people may not recognize that they are in abusive situations or may be reluctant to admit it due to guilt , fear , shame or denial .

79. 8. Functional Assessment (Including Activities of Daily Living) If the person responds to feeling unsafe, follow - up with close-ended questions. Ask: " Have you ever been emotionally or physically abused by your partner or someone important to you?" “ Within the last year, have you been hit, slapped, kicked, pushed, or shoved, or otherwise physically hurt by your partner or ex-partner?"

80. 8. Functional Assessment (Including Activities of Daily Living) "If yes, by whom?" "Number of times?" "Does your partner ever force you into having sexual intercourse?" "Are you afraid of your partner or ex-partner? 11. Occupational Health Ask the patient to describe his or her job. "Ever worked with any health hazard such as inhalants, chemicals?" "Wear any protective equipment?"

81. 8. Functional Assessment (Including Activities of Daily Living) "Any work programs in place that monitor exposure?" "Aware of any health problem now that may be related to work exposure?" Perception of Health Ask: "How do you define health?" "How do you view your situation now?" "What are your concerns?" "What do you think will happen in the future?" "What are your health goals?" "What do you expect from nurses and physicians or other healthcare providers?

82. Developmental Competence Record the parent's spontaneous statement. Reasons given by parents may be, "time for the child's check-up," "she needs the next vaccine/ immunization." A parent may have a "hidden agenda" such as a mother bringing her 4-year old child to the clinic because the child "looked pale." Further questioning revealed that the mother had heard recently from a friend who's own 4 - year old child had just been diagnosed with leukemia. A. Additional information for health history for pediatric patients. Reason for Seeking Care ✔️ ✔️

83. Developmental Competence Include a statement about the usual health of the child and any common health problems or major health concerns. Present Health or History of Present Illness ✔️ ✔️ Examples: The child's health status is generally good as stated by mother. The child's weight is within normal range for age. The child had "one asthmatic attack" for the past 3 months. The child is in pain, as claimed by the mother.

84. Developmental Competence Describe any presenting sign or symptom. Use the same format as for the adult. Some additional considerations include: Present Health or History of Present Illness ✔️ Severity of Pain "How do you know, the child is in pain?" (e.g. "pulling at ears," "turning the head from side to side," "fussiness," "curls up knees over the abdomen."

85. Developmental Competence Effect of Pain on Usual Behavior "Refuses feeding." "Stops him/her from playing." "Refuses to go to school." "Stays in bed most of the time." Parent's coping ability and reaction of other family member to child's symptoms or illness.

86. Past Health Prenatal Status ✔️ How was this pregnancy spaced? Was it planned? What was the mother's attitude to this pregnancy? What was the father's attitude to this pregnancy? Was there medical supervision for the mother? At what month was the supervision started? What was the mother's health during pregnancy?

87. Past Health Were there any complications (e.g., bleeding, excessive nausea and vomiting, unusual weight gain, high blood pressure, swelling of hands and feet, infections German measles/rubella, sexually— transmitted disease, falls)? What diet and medications were prescribed and/or take during pregnancy? Did the mother smoke, take alcohol, use street drugs during pregnancy?

88. Past Health Did the mother undergo any x-ray studies during pregnancy? Start with an open — ended question: "Tell me about your pregnancy?" Explain to the mother that these questions are important to gain a complete picture of the child's health.

89. Past Health Labor and Delivery ✔️ Parity of the mother (e.g., Gravida Para) Duration of pregnancy (e.g., 9 months) Place of delivery (e.g., Lying - in clinic, hospital, home) Type of delivery (e.g., normal/vaginal delivery, Cesarean section, vertex (head is presenting part), breech (buttocks is presenting part)

90. Past Health Birth weight, birth length, head circumference, chest circumference, Apgar Scores, onset or breathing, any cyanosis, need for resuscitation and use of special equipment or procedure.

91. Past Health Postnatal Status ✔️ Any problems in the nursery? Length of hospital stay Neonatal jaundice (e.g., after 24 hours, first 24 hours of birth) " Whether the baby was discharged with the mother, or needed to stay longer in the nursery Whether the baby was breast — fed or bottle — fed

92. Past Health ✔️ Any feeding problems, "blue — spells," "colic diarrhea" Patterns of crying and sleeping Mother's health postpartum Mother's reaction to the baby

93. Past Health Childhood Illnesses ✔️ Age when any of the following illness/es was/ were experienced: measles, mumps, rubella, chickenpox, whooping cough, sore throat/ strep throat, ear infections. Any complications experienced from the aforementioned diseases. Serious Accidents or Injuries Age of occurrence

94. Past Health Extent of injury How the child was treated Complication of auto accidents, falls, head injuries, fractures, burns and poisonings.

95. Past Health Serious or Chronic Illnesses ✔️ Age of onset " How the child was treated? Were there complications? Examples: Meningitis Diabetes Encephalitis Kidney problems Seizure disorder High Blood Pressure Asthma Tuberculosis Pneumonia Otitis Media Rheumatic Fever Allergies

96. Past Health Operations or Hospitalizations ✔️ Reason for care Age of admission Name of physician and hospital Duration of stay How the child reacted to hospitalization Any complications

97. Past Health Immunizations ✔️ Age when administered Date administered Any reactions following immunizations Allergies ✔️ Any foods, drugs, contact agents, environmental agents to which the child is allergic, reaction to allergen.

98. Past Health Examples of Allergens: Eggs, peanut butter, snack foods, shrimp Aspirin, acetaminophen, penicillin Dust, pollens, grass, molds, roaches, animal danders Extremes of temperature (cold or warm weather) Examples of reactions to allergens Skin rashes Difficulty of breathing Swollen eyelids and lips Nausea and vomiting Diarrhea

99. Past Health Medications ✔️ Any prescription and over-the-counter medications (or vitamins) the child takes, including the dose, daily schedule, why the medication is given and any problems.

100. Developmental History Growth ✔️ Height and weight at birth and at 1, 2, 5 and 10 years Process of dentition (age of tooth eruption and pattern of loss) Milestones ✔️ Motor development (e.g. age when child first held head erect, rolled over, sat up, walked alone, tied shoes, dressed without help) Language (e.g. age when child first said "mama," "dada") Toilet training (e.g. age when the child achieved bowel and bladder control)

101. Developmental History Do the parents believe this development has been normal? How does this child's development compare with siblings or peers? Current Development ✔️ Gross Motor Skills (rolls over, sits alone, walks alone, skips, climbs) Fine Motor Skills (brings hands to mouth, pincer grasp, stacks blocks, feeds self, uses crayons to draw, uses scissors) Language Skills (first words with meaning, vocabulary, sentences, persistence of baby talk)

102. Developmental History Personal — Social Skills (smiles, follows movement with eyes, turns head towards sounds, recognizes own name) Toilet - training (method used, age of bowel/ bladder control, parents' attitude towards toilet — training, terms used for toileting)

103. Nutritional History Frequency, amount, duration, supplements (vitamins, iron), method of weaning Any problems with bottle - feeding (spitting up, colic, diarrhea) Introduction of solid foods — what foods are given, child's reaction to new food Breast feeding or bottle — feeding (for infants) ✔️

104. Nutritional History Appetite to eat 24 - hour diet recall (meals, snacks, amounts) Vitamins taken How much junk food is eaten Foods likes and dislikes Parent's perception of child's nutrition For preschool, school — age children and adolescents ✔️

105. As with the adult, ask for family history of heart disease, high blood pressure, diabetes, blood disorders, cancer, arthritis, allergies, obesity, tuberculosis, mental illness, seizure disorder, kidney disease, alcoholism, mental retardation, learning disabilities, birth defects Family History

106. Developmental Competence Adolescents (younger than 19 years old) have an increased incidence of anemia, pregnancy - induced hypertension/PIN, preterm labor/PTL, small — for — gestational (SGA) infants, intrauterine - growth — retardation /IUGR, cephalo-pelvic disproportion/CPD, and dystocia (prolonged, difficult, painful labor). B. Additional Information for Health History in Pregnancy Age ✔️

107. Developmental Competence Women of advanced maternal age (over 35 years of age) have increased incidence of hypertension, pregnancies complicated by underlying medical problems such as diabetes, medical gestation, and infants with genetic abnormalities. ✔️ Family History Maternal and Paternal History Congenital disorders, hereditary diseases, multiple pregnancies, diabetes, heart disease, hypertension, mental retardation, renal disease or use of diethylstilbestrol (DES) ✔️ ✔️

108. Developmental Competence * Note : Daughters born to mothers who sustained their pregnancies with DES may have uterine anomalies that increase their risk of preterm labor (PTL) or uterine hyperstimulation). Woman's Medical History Childhood diseases (e.g. rubella measles, chickenpox) Major illnesses, surgery (especially of the reproductive tract), blood transfusions Drug, food, environmental allergens Urinary infections, heart disease, diabetes, hypertension, endocrine disorders, anemias ✔️ ✔️ ✔️ ✔️

109. Developmental Competence Use of oral or other contraceptives. History of sexually - transmitted diseases. Menstrual history - start of menarche, duration, amount, regularity and pain (dysmenorrhea, bleeding between periods (metrorrhagia). Use of medications - prescription, over-the-counter OTC's, other drugs, alcohol, tobacco, caffeine. History of TB, hepatitis, group B beta streptococcus, or human immunodeficiency virus (HIV). ✔️ ✔️ ✔️ ✔️ ✔️

110. Woman's Present Obstetric History Gravida ( G ) - woman who is or has been pregnant, regardless of pregnancy outcome; regardless of the number of fetuses. Para (P) - refers to the past pregnancies that have reached viability. Nulligravida - woman who is not now and never has been pregnant. Primigravida - woman who has been pregnant for the first time. Multigravida - woman who has been pregnant more than once Nullipara - woman who has never completed a pregnancy to the period of viability (capability of living, 24 weeks)

111. Woman's Present Obstetric History Primipara - woman who has completed one pregnancy to the period of viability regardless of the number of infants delivered and regardless of the infant being live or stillborn. Multipara - woman who has completed two or more pregnancies to the stage of viability. Examples: G1P0 - a woman pregnant for the first time (primigravida) G2P1 - a woman who is pregnant for the second time and has delivered one fetus carried to the period of viability

112. Woman's Present Obstetric History Obstetric history may be summarized by a series of 4 digits using the abbreviation TPAL or by a series of 6 digits using the abbreviation GTPALM . T - erm / full term deliveries; 37 completed weeks or more. P - reterm deliveries; 20 to less than 37 completed weeks A - bortions; elective or spontaneous loss of a pregnancy before the period of viability (less than 20 weeks) L - iving children a woman has delivered regardless of whether they were live births or stillborn births

113. Woman's Present Obstetric History G7-T5-P0-A2-L5 The woman had been pregnant 7 times, has 5 term deliveries, O preterm, 2 abortions and 5 living children G - ravida T - erm / Full term deliveries P - reterm deliveries (20 to less than 37 completed weeks) Example:

114. Woman's Present Obstetric History G5-T5-P0-A0-L6- M1 The woman had been pregnant 5 times, has 5 term deliveries, O preterm, 0 abortion, 6 living children and 1 multiple gestation/birth. Example: A - bortions (less than 20 weeks) L - living children M - ultiple gestations and births (not the number of neonates delivered)

115. Woman's Present Obstetric History Date of last menstrual period (LIMP)First day of last menstrual period Estimated date of birth — expected date of delivery (EDD) ✔️ ✔️

116. Woman's Present Obstetric History Nagele's Rule: Expected date of delivery 1. lst day of LMP (last menstrual period): January to March Month Day Year +9 +7 same Year

117. Woman's Present Obstetric History Nagele's Rule: Expected date of delivery Example: LMP January 3, 2020 1 3 2020 +9 +7 EDD October 10, 2020 10 10 2020

118. Woman's Present Obstetric History Nagele's Rule: Expected date of delivery 2. Ist day of LMP (last menstrual period): April to December Month Day Year -3 +7 +1

119. Woman's Present Obstetric History Nagele's Rule: Expected date of delivery Example: LMP June 2, 2020 6 2 2020 -3 +7 EDD March 9, 2021 3 9 2021 +1

120. Woman's Present Obstetric History Signs and symptoms of pregnancy : amenorrhea (absence of menstruation), breast changes, nausea and vomiting, urinary frequency, skin pigmentation, enlargement of the abdomen, fetal movement. ✔️ Rest and Sleep Patterns - length, quality, and regularity of rest and sleep. Activity and Employment - exercise patterns, type and hours of employment, exposure to hazardous material, plans for continued employment. ✔️ ✔️

121. Functional Assessment (Including Activities of Daily living) Interpersonal Relationships Within the family constellation, record the child's position in family; whether the child is adopted; who lives with the child; who is the primary caregiver; who is the caregiver if both parents work outside the home; any support from relatives, neighbors, or friends; and the ethnic or cultural milieu. Indicate family cohesion. Does the family enjoy activities as a unit? Has there been a recent family change or crisis (death, separetion, move)? Record information on child's self-image and level of independence.

122. Functional Assessment (Including Activities of Daily living) Interpersonal Relationships Within the family constellation, record the child's position in family; whether the child is adopted; who lives with the child; who is the primary caregiver; who is the caregiver if both parents work outside the home; any support from relatives, neighbors, or friends; and the ethnic or cultural milieu. Indicate family cohesion. Does the family enjoy activities as a unit? Has there been a recent family change or crisis (death, separetion, move)? Record information on child's self-image and level of independence.

123. Functional Assessment (Including Activities of Daily living) Activity and Rest Record and child's play activities. Indicate amount of active and quiet play, outdoor play, time watching television, and special hobbies or activities. Record sleep and rest. Indicate pattern and number of hours at night and during the day and the child's routine at bedtime. Record school attendance. Any experience with daycare or nursery school?In what grade is the child in school? Has the child ever skipped a grade or been held back? Does the child seem to like school? What is his or her school performance? Are the parent and child satisfied with the performance?

124. Functional Assessment (Including Activities of Daily living) Activity and Rest Record and child's play activities. Indicate amount of active and quiet play, outdoor play, time watching television, and special hobbies or activities. Record sleep and rest. Indicate pattern and number of hours at night and during the day and the child's routine at bedtime. Record school attendance. Any experience with daycare or nursery school?In what grade is the child in school? Has the child ever skipped a grade or been held back? Does the child seem to like school? What is his or her school performance? Are the parent and child satisfied with the performance?

125. Functional Assessment (Including Activities of Daily living) Economic Status. Ask about the mother's and father's occupations. Indicate the number of hours each parent is away from home. Do parents perceive their income to be adequate? What is the effect of illness on financial status? Home Environment. Where does family live (house, apartment)? Is the size of the home adequate? Is there access to an outdoor play are? Does the child share a room, have his or her own bed, and have toys appropriate for his or her age?

126. Functional Assessment (Including Activities of Daily living) Environmental Hazard. Inquire about home safety (precautions for poisons, medications, household products, presence of gates for stairways, and safe yard equipment). Inquire about the home structure (adequate heating, ventilation, bathroom facilities), neighborhood (residential or industrial, age of neighbors, safe play areas, playmates available, distance to school, amount of traffic, whether area remote or congested and overcrowded, if crime is a problem, presence of air or water pollution), and automobile (child safety seat, seatbelts).

127. Functional Assessment (Including Activities of Daily living) Coping/Stress Management. Is the child able to adapt to new situation? Record recent stressful experiences (death, separation, move, loss of special friend. How does the child cope with stress? Any recent change in behavior or mood? Has counseling ever been sought? Habits. Has the child ever tried cigarette smoking? How much did he or she smoke? Has the child ever tried alcohol? How much alcohol did he or she drink weekly or daily? Has the child ever tried other drugs (marijuana, cocaine, amphetamines, barbiturates)?

128. Functional Assessment (Including Activities of Daily living) Health Promotion. Who is the primary health care provider? When was the child's last checkup? Who is the dental care provider and when was the last dental checkup? Provide date and result of screening for vision, hearing, urinalysis, phenylketonuria, hematocrit, TB skin test, stickle cell trait, blood lead, and other tests specific for high-risk populations.

129. The Adolescent This section presents a psychosocial review of symptoms intended to maximize communication with youth. The HEEADSSS method of interviewing focuses on assessment of the: H - ome environment, E - ducation and employment, E - ating, A - ctivities, peer-related D - rugs, S - exuality, S - uicide/ depression, and S - afety from injury and violence.

130. The Adolescent The tool minimizes adolescent stress because it moves from expected and less-threatening questions to those that are more personal. It presents the questions in three colors : green are considered essential to explore with every adolescent; blue are important for you to ask if time permits; red questions delve more deeply if the situation demands it. Interview the youth alone while the parent waits outside and fills out past health questionnaires. Green = essential question Blue = as time permits Red = optional or when situation requires

131. The Adolescent In addition ask, "How many hours of sleep do you get on most nights of the week? What time do you actually go to bed? What time do you wake up on school days? What time would you wake up if left alone? *Note that teens need about 9 hours of sleep per night, yet most Philippine teens get less than that. Older teens report <6.5 to 7 hours per night; younger teens report 7.7 hours per night.

132. Home The HEEADSSS Psychosocial Interview for Adolescent Who lives with you? Where do you live? Do you have your own room? What are relationships like at home? To whom are you closest at home? To whom can you talk at home? Is there anyone new at home? Has someone left recently? Have you moved recently? Have you ever had to live away from home? (Why?) Is there any physical violence at home?

133. Education and Employment The HEEADSSS Psychosocial Interview for Adolescent What are your favorite subjects at school? Your least favorite subjects? How are you grades? Any recent changes? Any dramatic changes in the past? Have you changed schools in the past few years? What are your future education/ employment plans/ goals? Are you working? Where? How much? Tell me about your friends at school. Is your school a safe place? (Why?)

134. The HEEADSSS Psychosocial Interview for Adolescent Have you ever had to repeat a class? Have you ever had to repeat a grade? Have you ever been suspended? Expelled? Have you ever considered dropping out? How well do you get along with the people at school? Work? Have your responsibilities at work increased? Do you feel connected to your school? Do you feel as if you belong? Are there adults at school you feel you could talk to about something important? (Who?)

135. Eating The HEEADSSS Psychosocial Interview for Adolescent What do you like and not like about your body? Have there been any recent changes in your weight? Have you dieted in the past year? How? How often? Have you done anything else to try to manage your weight? How much exercise do you get in an average day? Week? What do you think would be a healthy diet? How does that compare with your current eating patterns? Do you worry about your weight? How often?

136. The HEEADSSS Psychosocial Interview for Adolescent Do you eat in front of the TV? Computer? Does it ever seem as though your eating is out of control? Have you ever made yourself throw up on purpose to control you weight? Have you ever taken diet pills? What would it be like if you gained (lost) 10 pounds?

137. Activities The HEEADSSS Psychosocial Interview for Adolescent What do you and your friends do for fun? (with whom, where, and when?) What do you and your family do for fun? (with whom, where, and when?) Do you participate in any sports or other activities? Do you regularly attend a church group, club, or other organized activity? Do you have any hobbies? Do you read for fun? (What?)

138. Drugs The HEEADSSS Psychosocial Interview for Adolescent How much TV do you watch in a week? How about video games? What music do you like to listen to? Do any of your friends use tobacco? Alcohol? Other drugs? Does anyone in your family use tobacco? Alcohol? Other drugs? Do you use tobacco? Alcohol? Other drugs? Is there any history of alcohol or drug problems in your family? Do you ever drink or use drugs when you're alone? (Assess frequency, intensity, patterns of use or abuse, and how youth obtains or pays for drugs, alcohol, or tobacco.)

139. Sexuality The HEEADSSS Psychosocial Interview for Adolescent Have you ever been in a romantic relationship? Tell me about the people that you've dated. Or tell me about your sex life. Have any of your relationships ever been sexual relationships? Are your sexual activities enjoyable? What does the term "safe sex" mean to you? Are you interested in boys? Girls? Both? Have you ever been touched sexually in a way that you didn't want? How many sexual partners have you had altogether?

140. The HEEADSSS Psychosocial Interview for Adolescent Have you ever been pregnant or worried that you may be pregnant? (females) Have you ever gotten someone pregnant or worried that might have happened? (males) What are you using for birth control? Are you satisfied with your method? Do you use condoms every time you have intercourse? Does anything ever get in the way of using a condom? Have you ever had a sexually transmitted infection (STI) or worried that you had an STI?

141. Suicide and Depression The HEEADSSS Psychosocial Interview for Adolescent Do you feel sad or down more than usual? Do you find yourself crying more Are you "bored" all the time? Are you having trouble getting to sleep? Have you thought a lot about hurting yourself or someone else? Does it seem that you've lost interest in things that you used to really enjoy? Do you find yourself spending less and less time with friends? Would you rather just be by yourself most of the time?

142. The HEEADSSS Psychosocial Interview for Adolescent Have you ever tried to kill yourself? Have you ever had to hurt yourself (by cutting yourself, for example) to calm down or feel better? Have you started using alcohol or drugs to help you relax, calm down, or feel better?

143. Safety (Savagery) The HEEADSSS Psychosocial Interview for Adolescent Have you ever been seriously injured? (How?) How about anyone else you know? Do you always wear a seatbelt in the car? Have you ever ridden with a driver: who was drunk or high? When? How often? Do you use safety equipment for sports and /or other physical activities (e.g., helmets for biking or skateboarding)? Is there any violence in your home? Does the violence ever get physical?

144. The HEEADSSS Psychosocial Interview for Adolescent Is there a lot of violence at your school? In your neighborhood? Among your friends? Have you ever been physically or sexually abused? Have you ever been raped, on a date or at any other time? (If not asked previously) Have you ever been in a car or motorcycle accident? (What happened?) Have you ever been picked on or bullied? Is that still a problem?

145. The HEEADSSS Psychosocial Interview for Adolescent Have you gotten into physical fights in school or your neighborhood? Are you still getting into fights? Have you ever felt that you had to carry a knife, gun, or other weapon to protect yourself? Do you still feel that way?

146. THANK YOU