The components of health history are biographic data, reasons for seeking care/chief complaint, history, past health history, family health history, current medication, lifestyle, developmental level and psychosocial history.
Biographic data in the health history includes name, address and contact number, age and birthdate, sex, marital status, race, ethnic origin, occupation, and language and communication needs.
Students can prepare index cards or half-sheets of paper to write feedback to the following questions: "What was the most useful or the most meaningful thing you have learned this session?" and "What question(s) do you have as we end this session?".
While gathering data for the family history portion of the health history, it's important to ask about suicide, number of siblings, family ethnicity, and religion.
The chief complaint is a brief spontaneous statement in the patient’s own words that describes the reason for the visit, stating one or two signs and symptoms and their duration.
Document who accomplishes the information in the health history (patient or next of kin), judge how reliable the data seems and how willing the patient to communicate, and note any special circumstances, such as use of interpreter.
For ill patients, the present health or history of present illness is a chronological record of the reason for seeking care, from the time the symptom first started until now.
The final summary of any symptoms should include the following critical characteristics using the mnemonic PQRSTU to help remember all the points and organize questions sequences.
Current medications/ medication reconciliation Note all prescription and OTC medications and herbal supplements, ask specifically for vitamins, birth control pills, ASA, and anticoagulants / blood thinners
Providing the patient with a printed history to complete and then comparing the data provided is most appropriate to verify the reliability of the information provided by the patient during the interview.
Hospitalization Cause, name of the hospital, how the condition was treated, how long the person was hospitalized and name of the primary health care provider