Health History Form
Name Date
Directions Using the Health History Guidelines and Rubric complete the chart below with your participant. Please review the rubric prior to gathering your data to assure proper completion of the assignment.
Criteria
Data
BIOGRAPHICAL DATA
Date
Initials
Age
Date of birth
Birthplace
Gender
Marital status
Race
Religion
Occupation
Reliability of source of information
PRESENT HEALTH HISTORY/ILLNESS
When do they seek care
Current health status
Health goals
HEALTH BELIEFS AND PRACTICES
Beliefs and practices (exercise patterns, alcohol/drug use, how do they get to work, do they wear a seat belt)
Factors influencing healthcare decisions
MEDICATIONS
Prescription medications
Over-the-counter medications
Herbals
PAST HISTORY
Childhood diseases
Immunizations
Allergies
Major illnesses
Injuries
Hospitalizations
Pregnancies and deliveries
Surgeries
EMOTIONAL HISTORY
emotional psychiatric or substance use related problems
FAMILY HISTORY
Father
Mother
Siblings
Grandparents
PSYCHOSOCIAL/ OCCUPATIONAL HISTORY
Support systems
Occupational history
Educational level
Is money a source of concern
ROLES AND RELATIONSHIPS
Participant’s roles and relationships
Community based activities
ETHNICITY AND CULTURE
Ethnicity and culture
Social traits that influence healthcare decisions
SPIRITUALITY
Religious and spiritual needs
SELF-CONCEPT
View of self-worth (who and what they are)
Future goals
REVIEW OF SYSTEMS (Please refer to your assignment guidelines. This is NOT a physical assessment.)
Skin, hair, nails
Head, neck, related lymphatics
Eyes
Ears, nose, mouth, and throat
Respiratory
Breasts and axillae
Cardiovascular
Peripheral vascular
Abdomen
Endocrine
Urinary
Reproductive
Musculoskeletal
Neurologic
Select your paper details and see how much our professional writing services will cost.
Our custom human-written papers from top essay writers are always free from plagiarism.
Your data and payment info stay secured every time you get our help from an essay writer.
Your money is safe with us. If your plans change, you can get it sent back to your card.
We offer more than just hand-crafted papers customized for you. Here are more of our greatest perks.
Get instant answers to the questions that students ask most often.
See full FAQWe complete each paper from scratch, and in order to make you feel safe regarding its authenticity, we check our content for plagiarism before its delivery. To do that, we use our in-house software, which can find not only copy-pasted fragments, but even paraphrased pieces of text. Unlike popular plagiarism-detection systems, which are used by most universities (e.g. Turnitin.com), we do not report to any public databases—therefore, such checking is safe.
We provide a plagiarism-free guarantee that ensures your paper is always checked for its uniqueness. Please note that it is possible for a writing company to guarantee an absence of plagiarism against open Internet sources and a number of certain databases, but there is no technology (except for turnitin.com itself) that could guarantee no plagiarism against all sources that are indexed by turnitin. If you want to be 100% sure of your paper’s originality, we suggest you check it using the WriteCheck service from turnitin.com and send us the report.
Yes. You can have a free revision during 7 days after you’ve approved the paper. To apply for a free revision, please press the revision request button on your personal order page. You can also apply for another writer to make a revision of your paper, but in such a case, we can ask you for an additional 12 hours, as we might need some time to find another writer to work on your order.
After the 7-day period, free revisions become unavailable, and we will be able to propose only the paid option of a minor or major revision of your paper. These options are mentioned on your personal order page.