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Student’s Name: Health History Instructions: These statements must come from the patient and not any additional source. The patient statements represent subjective data and must be presented in quotes. Biographical Data: Birth date: ________ Age: ___ Gender: ______ Marital Status: ______ Reason for seeking health care:

Past Health (document the date for each area below) Childhood illnesses:

Adult illnesses: Immunizations (Td/Tdap; HPV; MMR; varicella; influenza; hepatitis B, hepatitis A; herpes zoster; meningococcal, herpes zoster) Accidents or injuries:

Hospitalizations: Surgeries:

Allergies (medicine, food, environmental agents, & latex) & the reaction for each Obstetric history: Gravida (# pregnancies) Para (# children born) Ab (incomplete pregnancies or abortions) Family history: (Document family health history.) Mother: Father: Siblings: Children:

Copyright 2018 University of Texas Medical Branch School of Nursing

Lifestyle & Health Practice: Current medications (prescription, over the counter, and herbal)

Personal habits: Tobacco use: (# packs /day x # years = pack year history) Have they ever tried to stop? Alcohol consumption: Have they ever tried to stop? Recreational drug use (marijuana, crack, cocaine, amphetamines, barbiturates, LSD, heroin, meth, etc.) Ever been in Rehab or tried to stop? Occupational health: Occupation: Work hazards Injuries: Chemicals: Equipment: Inhalants: Repetitive Motion: Hobbies: This section is based on observation and the implementation that occurred as a result of the findings. It will also include a patient assessment and observation. Environmental Scan: Indicate what you see within the patient’s environment and the steps you took to address the patient regarding the situations. It is time to look, listen, inspect, analyze and think about environment before you. Copyright 2018 University of Texas Medical Branch School of Nursing...