COMPREHENSIVE ADULT HEALTH HISTORY

Date:______________________
Time: ______________________

IDENTIFYING DATA
 Name:

 Age:
 Gender:
 Address:
 Marital status
 Occupation

 Source of the history:

RELIABILITY

CHIEF COMPLAINT (S)

 Amplifies the Chief Complaint; describes how each symptom developed

HISTORY OF PRESENT ILLNESS
 Location
o Radiates/ refers to

 Quality

 Quantity or severity

 Timing
o Onset

o duration

o frequency

o time (am/pm)

 setting in which it occurs

 Aggravating factors

 Relieving factors

 Associated manifestations or
symptoms

 Medication taken
o Name / Dose /Route /Frequency
of use / Reaction to med
 Allergies (if related to present illness)

 tobacco use (if related to present illness)

 1½ packs a day for 12 years = an 18-pack/ year
history ; If someone has quit, note for how long.
 Alcohol and drug use (if related to
present illness)
HISTORY OF PRESENT ILLNESS
PAST HISTORY

Childhood Illnesses
 Measles  Rubella  Mumps  whooping  chickenpox
cough

 rheumatic  scarlet fever  polio  chronic 

fever childhood
illnesses.

Adult Illnesses - when was diagnose, duration of

illness and Medications

Medical
 Diabetes  Hypertension  Hepatitis  Asthma  human
immunodeficiency
virus (HIV)

 hospitalizations  number of sexual  gender of sexual  risk-taking sexual

partners partners practices

Surgical:
 Dates  indications  types of operations

Obstetric/Gynecologic:
 Obstetric history  Gravida  Term  Alive  complications
 Para  Preterm  Aborted
  Living

 method of delivery  menstrual history  methods of 

contraception

Psychiatric:
 Illness  time frame  diagnosis  hospitalizations

 treatments  medications

Health Maintenance:

immunizations
 tetanus  varicella  tuberculin tests  results of labs
 pertussis  hepatitis B  Pap smears  when they were
 diphtheria  HPV  mammograms last performed
 polio  meningococcal  stool tests for
 measles disease occult blood
 rubella  Haemophilus  colonoscopy
 mumps influenzae type B  cholesterol tests
 influenza  Pneumococci
 herpes zoster
 age and health
 age and cause of death
FAMILY HISTORY  symptoms reported by the patient.
 breast, ovarian, colon, or prostate cancer, genetically transmitted diseases

 hypertension  thyroid disease  headache

 coronary artery  renal disease,  seizure disorder
disease  arthritis  mental illness,
 elevated choles levels  tuberculosis  suicide,
 stroke  asthma or lung  substance abuse
 diabetes disease  allergies

 Mother  Father  Siblings  Children  Grandchildren

 Grandparents

PERSONAL AND SOCIAL HISTORY

 patient’s personality and
personal interest
 Family origin

 sources of support

 coping style, strengths, and

concerns
 occupation

 Educational level

 Household / home situation and

significant others
 Sources of stress, both recent
and long-term
 Job history

 financial situation, and

retirement
 leisure activities; and activities of
daily living (ADLs)
 religious affiliation and spiritual
beliefs
 Exercise and diet; dietary
supplements or restrictions
 safety measures

sexual orientation and practices

and any alternative health care
practices
 tobacco, drug, and alcohol
 REVIEW OF SYSTEM

General
 recent weight change  weakness  fatigue  fever 

Skin:
 Rashes  lumps  sores  itching  dryness

 changes in color  changes in hair/ nails  changes in size or  Lesions 

color of moles

Head
 Headache  head injury  dizziness  lightheadedness 

Eyes:
 Vision  glasses or contact  last examination  
lenses
 pain  redness  excessive tearing  double or blurred  spots
vision
 specks  flashing lights  glaucoma  cataracts 

Ears
 Hearing  tinnitus  vertigo  earaches  infection

 discharge  If hearing is  use /  nonuse of  

decreased hearing aids

Nose and sinuses:

 Frequent colds  nasal stuffiness  discharge, or itching  hay fever  nosebleeding
 sinus trouble  growth   

Throat (or mouth and pharynx):

 Dentures / appliance  Condition of teeth  bleeding gums  last dental  sore tongue
how they fit and gums examination
 dry mouth  frequent sore throats  hoarseness  thrush 

Neck:
 Swollen glands  enlarged thyroid/goiter  lumps  pain  stiffness in the neck
    

Breasts:
 Lumps  pain or discomfort  nipple discharge  self-examination  breastfeeding
practices.
    

Respiratory:
 Cough  productive  sputum (color,  hemoptysis  shortness of breath  wheezing
 non-productive quantity) (dyspnea)
 pain with a deep  asthma  bronchitis  emphysema  pneumonia
breath (pleuritic pain)
 tuberculosis  last chest x-ray   
Cardiovascular:
 high blood pressure  rheumatic fever  heart murmurs  chest pain or  palpitations
discomfort
 shortness of breath  need to use pillows at  paroxysmal nocturnal  edema 
night to ease breathing dyspnea
(orthopnea)
 results of past   other cardiovascular  
electrocardiograms tests

Gastrointestinal:
 Trouble swallowing  heartburn  appetite  nausea  vomiting
 Bowel movements  stool color and size  change in bowel  pain with defecation  rectal bleeding
habits
 black or tarry stools  hemorrhoids  constipation  diarrhea  Abdominal pain
 food intolerance  excessive belching or  Jaundice  liver  gallbladder problems
passing of gas
 hepatitis    

Peripheral vascular
 Intermittent leg pain  leg cramps  varicose veins  past clots in the veins  swelling in calves,
with exertion legs, or feet
(claudication)
 color change in  swelling with redness   
fingertips or toes or tenderness.
during cold weather

Urinary:
 Frequency of  polyuria  nocturia  urgency  burning or pain
urination during urination
 blood in the urine  urinary infections  kidney or flank pain  kidney stones  ureteral colic
(hematuria)
 suprapubic pain  incontinence  reduced caliber or  dribbling (male) 
force of the urinary
stream, hesitancy (male)

Genital:

Male:
 Hernias  discharge from or  testicular pain  testicular masses  scrotal pain or
sores on the penis swelling
 history of sexually  treatments.  Sexual habits,  birth control  Concerns about HIV
transmitted infections interest, function, methods, condom use, infection.
satisfaction and problems.

Female:
 Age at menarche  regularity menst.  frequency  duration of periods  amount of bleeding
 irregular

 bleeding between  bleeding after  dysmenorrhea  last menstrual period 

periods intercourse
 premenstrual tension  Age at menopause  menopausal   postmenopausal
symptoms bleeding
 exposure to  Vaginal discharge  itching  sores  lumps
carcinogenic during
pregnancy (DES)
 sexually transmitted  treatments.  Number of  number and type of 
infections pregnancies deliveries
 number of abortions  complications of  birth-control  Sexual preference  interest, function,
(spontaneous and pregnancy methods satisfaction
induced)
 dyspareunia  Concerns about HIV   
infection

Musculoskeletal:
 Muscle or joint pain  stiffness  arthritis  gout  backache
 If present, describe  swelling  redness  pain  tenderness
location of affected
joints or muscles
   weakness  limitation of motion 
or activity
 timing of symptoms   duration  any history of trauma 
(e.g., morning or
evening)
 neck pain  low back pain  Joint pain with  
systemic symptoms
(fever, chills, rash, anorexia,
weight loss, or weakness)

Psychiatric:
 Nervousness  tension  mood  depression  memory change

 suicidal ideation  suicide plans or  Past counseling  psychotherapy  psychiatric

attempts. admissions
 medication    

Neurologic:
 Changes in mood or  changes in speech  changes in  headache 
attention orientation/ memory/
judgment
 dizziness  vertigo  fainting  blackouts  weakness
 paralysis  numbness or loss of  tingling or “pins and  tremors  involuntary
sensation needles,” movements
 seizures    

Hematologic
 Anemia  easy bruising or  past transfusions   transfusion reactions
bleeding

Endocrine:
 thyroid problem  heat or  cold  excessive sweating  excessive thirst or  polyuria
intolerance hunger
 change in glove or    
shoe size

    

    