Health History Guideline
NUR3069 Page 1 of 4
Use this guide to gather patient information for the Comprehensive Health History
Assignment.
Subject Criteria
Possible
Points
Patient Demographics
• Gender, age, ethnicity, and other social
demographics as indicated (self-pay, Insurance) 5
Chief Complaint
• In the patient’s own words, describe one or more
symptoms or concerns that cause the patient to seek
care.
• Elaborate on the chief complaint; describe how each
symptom developed.
• Include the patient’s thoughts and feelings about the
illness.
5
History of Present
Illness
• Appropriate dimensions of cardinal symptoms are
listed (including location, severity, quality, setting,
chronology, aggravating/alleviating, and associated
manifestations)
• HPI narrative flows smoothly in a logical fashion
• For those students who favor mnemonics, the 8
dimensions of a medical problem can be easily
recalled using OLD CARTS
(Onset, Location/radiation, Duration, Character, Aggr
avating factors, Relief factors, Timing, and Severity).
10
Past Medical History
• Lists childhood illnesses
• Lists adult illnesses with dates for at least three
categories: medical, surgical, and psychiatric.
• Medication, Allergies
• List patient’s health maintenance practices such as
immunizations, screening tests, lifestyle issues, and
home safety.
5
Current Health Status
• Summary of general health status related to the
present illness. 5
Health History Guideline
NUR3069 Page 2 of 4
Family History
Narrative and
Genogram
https://genopro.com/geno
gram/medical/
• Outlines or diagrams of age and health or age and
cause of death of siblings, parents, grandparents,
and children.
• Documents the presence or absence of specific
illnesses in the family (e.g., hypertension, coronary
artery disease)
• The family pedigree shows at least three generations
and involves standardized symbols, which mark
individuals affected with a specific diagnosis to allow
for easy identification.
10
Risk Assessment
Based on Family
History
• Family history of a known or suspected genetic
condition
• Ethnic predisposition to certain genetic disorders
• Consanguinity (blood relationship of parents)
• Multiple affected family members with the same or
related disorders
• Earlier than expected age of onset of disease
• Diagnosis in less-often-affected sex
10
Social History
• Have they ever smoked cigarettes? If so, how many
packs per day and for how many years? If they quit,
when did this occur?
• Do they drink alcohol? If so, how much per day and
what type of drink?
• Any drug use, past or present, should be noted.
• Work, family, friends, community support systems,
5
Past Surgical History
• Were they ever operated on, even as a child?
• What year did this occur?
• Were there any complications?
5
Health History Guideline
NUR3069 Page 3 of 4
Sexual Activity
• Do they participate in intercourse? With persons of
the same or opposite sex?
• Are they involved in a stable relationship?
• Do they use condoms or other means of birth
control?
• If married? The health of the spouse? If divorced?
Past sexually transmitted diseases?
• Do they have children? If so, are they healthy? Do
they live with the patient?
5
Work/Hobbies/Other
• What sort of work does the patient do?
• Have they always done the same thing? Do they
enjoy it?
• If retired, what do they do to stay busy? Any
hobbies?
5
Review of Systems
(ROS)
• Document the presence or absence of common
symptoms related to each central body system.
• Consider asking a series of questions going from
“head to toe.”
• The questions asked to reflect an array of standard
and critical clinical conditions (heart disease,
diabetes, arthritis) explicitly prompt the patient,
• Format
o General/skin/sleep
o HEENT
o Respiratory
o Cardiovascular
o Musculoskeletal
o Endocrine
o Gastrointestinal and Urinary
o Neuro/psych
10
Prevention and Health
Promotion
• List at least one prevention activity.
• List at least three health promotion
recommendations.
10
Health History Guideline
NUR3069 Page 4 of 4
APA Guidelines &
Writing Style
• APA (title page, margins, page numbers, headings,
subheadings, citations); spelling; writing
straightforward, concise, and professional.
10
Total 100
Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!
Step-by-Step Student Guide
Step 1: Start with Patient Demographics (5 pts)
-
Create a short introductory paragraph.
-
Include gender, age, ethnicity, insurance/self-pay status, and any other relevant social factors.
Step 2: Chief Complaint (5 pts)
-
Record what the patient says, in their own words.
-
Elaborate: describe onset, development of symptoms, and how the patient feels about the illness.
Step 3: History of Present Illness (10 pts)
-
Use OLD CARTS mnemonic: Onset, Location, Duration, Character, Aggravating/Relieving factors, Timing, Severity.
-
Write in smooth, narrative format (not just bullet points).
Step 4: Past Medical History (5 pts)
-
Childhood illnesses.
-
Adult illnesses with dates: medical, surgical, psychiatric.
-
Medications & allergies.
-
Health maintenance (immunizations, screenings, lifestyle).
Step 5: Current Health Status (5 pts)
-
Write a short paragraph summarizing overall health as it relates to the chief complaint.
Step 6: Family History & Genogram (10 pts)
-
Create a 3-generation family tree showing age, health, or cause of death.
-
Note conditions like hypertension, diabetes, cancer, etc.
-
Use standardized genogram symbols.
-
Resource: GenoPro Medical Genogram Guide
-
Step 7: Risk Assessment (10 pts)
-
Based on family history, outline: genetic conditions, ethnic predispositions, early onset diseases, multiple family members affected.
Step 8: Social History (5 pts)
-
Document: smoking, alcohol, drugs (past & present).
-
Work, family, friends, support systems.
Step 9: Past Surgical History (5 pts)
-
Surgeries (with years).
-
Any complications.
Step 10: Sexual Activity (5 pts)
-
Relationships, partners, birth control/condoms.
-
STD history.
-
Spouse/children’s health.
Step 11: Work/Hobbies/Other (5 pts)
-
Describe work type, satisfaction, or retirement activities.
-
List hobbies or daily routine.
Step 12: Review of Systems (10 pts)
-
Go head-to-toe.
-
Cover: general/skin/sleep, HEENT, respiratory, cardiovascular, musculoskeletal, endocrine, GI/urinary, neurological, psychiatric.
-
Document symptoms present/absent.
Step 13: Prevention & Health Promotion (10 pts)
-
At least 1 prevention activity (ex: annual flu shot).
-
At least 3 health promotion recommendations (ex: balanced diet, exercise, stress management).
Step 14: APA Guidelines & Writing Style (10 pts)
-
Title page, page numbers, 1-inch margins, headings/subheadings.
-
Cite sources when referencing disease risk factors, screening guidelines, or health promotion.
-
Write professionally: concise, clear, no slang.
Step 15: Final Checks
-
Ensure all rubric points are addressed.
-
Paper should read like a clinical interview summary.
-
Proofread grammar and APA formatting before submission.
Helpful Resources
The post Health History Guideline NUR3069 Comprehensive appeared first on Skilled Papers.