HEATH HISTORY FORMAT (GUIDELINE)
1. HEALTH HISTORY
a.
Introduction:-
b.
Patient’s
profile :
·
Name :
·
Hospital no :
·
Age………..Years
·
Gender
·
Address
·
Religion: Hindu/Muslim /Christian /Sikh /any
other
·
Marital status : married /singal/widow
·
Date and time of admission:
·
Ward /bed no:
·
Diagnosis : Medical/ Surgical
·
Date of surgery (if any):
·
Informant:
c. Chief complaint with duration (on the day
of admission X duration):
d.
History of
present illness: Presenting signs and symptoms/ onset/duration/ progress/
aggravating and relieving factors/ treatment taken.
e.
History of
past illness:
f.
Family history
( 3 generation genogram with key )
·
Type: joint /nuclear :
·
Number of members :
·
Any illness : TB, DM , HT ,Hereditary illness
/any other
g. Socio economic status :
i.
Social
Aspect :
·
Who makes decision on health matters
·
Support system
·
Neighbourhood relationship
·
Involvement in social activities , if
applicable.
ii.
Economic
status
·
Education
·
Occupation
·
Family income /month
·
Type of
house and ventilation
·
Toilet facility
·
Water source
h.
Nearest health
care facilities : PHC/ clinics / hospitals / others
i.
Personal
history :
·
Immunization
history
·
Dietary history
: vegetarian / Non vegetarian
No
. of Meals /day
Food
preference
·
Fluid intake ……………..glasses/day
·
Beverages………………..glasses /day
·
Personal hygiene
: Oral Hygiene : Frequency
Bath :frequency
·
Sleep and
rest :
·
Hours at night
·
Drugs used for sleeping
·
Uninterrupted /interrupted
·
Day time naps ……….hours /day
·
Activity and
exercise :
Daily walking / any other
Nature of work : sedentary /mild
/moderate/heavy
·
Habits/
hobbies:
Tobacco
/ alcohol / drug/ any other
·
Elimination
:
Bowel : Frequency
Regular /irregular /constipation
Bladder : Frequency at night
/day
j.
Marital
/ sexual history:
·
Married or widow /widower
·
Unmarried or unmarried mother
·
Spouse general health ; good /fair/bad
·
Spouse job status : working / not working
·
Staying together : yes /no
·
Relationship with spouse : satisfactory /
unsatisfactory
k. Female :
Menstrual history : age at
menarche / duration and frequency / any irregularities
Age at menopause / post-menopausal
problem , if any specify
l.
Male
:
Anything specific
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