A brief summary of your experiences in developing and implementing your script during your health history.
Assignment: (1- to 2-page reflection)
- In addition to your script for building a health history for this assignment, include a separate section called “Reflection” that includes the following:
- A brief summary of your experiences in developing and implementing your script during your health history.
- Explanations of what you might find difficult when asking these questions. What you found insightful and what would you say or do differently.
Answer
While taking a patient’s history, there’s a lot of information you need to gather in just a short amount of it
Determine the following:
1. Biographical data
Source of history
Name
Age
Occupation (past or present)
Marital status/living arrangement
2. Reason for seeking care and history of present health concern
Chief complaint
Onset of present health concern
Duration
Course of the health concern
Signs, symptoms, and related problems
Medications or treatments used (ask how effective they were)
What aggravates this health concern
What alleviates the symptoms
What caused the health concern to occur
Related health concerns
How the concern has affected life and daily activities
Previous history and episodes of this condition
3. Past health history
Allergies (reaction)
Serious or chronic illness
Recent hospitalizations
Recent surgical procedures
Emotional or psychiatric problems (if pertinent)
Current medications: prescriptions, over-the-counter, herbal remedies
Drug/alcohol consumption
4. Family history
Pertinent health status of family members
Pertinent family history of heart disease, lung disease, cancer, hypertension, diabetes, tuberculosis, arthritis, neurological disease, obesity, mental illness, genetic disorders
5. Functional assessment (including activities of daily living)
Activity/exercise, leisure and recreational activities (assess for falls risk)
Sleep/rest
Nutrition/elimination
Interpersonal relationships/resources
Coping and stress management
Occupational/environmental hazards
6. Developmental tasks
Current significant physical and psychosocial changes/issues
7. Cultural assessment
Cultural/health-related beliefs and practices
Nutritional considerations related to culture
Social and community considerations
Religious affiliation/spiritual beliefs and/or practices
Language/communication
