-
collect subjective data only
what the person says about himself or herself
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9 sections of the health history
- biographic data
- source of history
- reason for seeking care (symptoms only, not signs)
- history of present illness
- past health
- family history
- review of systems
- functional assessment (ADL's)
- perception of health
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8 critical characteristics of reported symptoms
- location
- character/quality
- quantity/severity
- timing
- setting
- aggravation/relieving factors
- associated factors
- patient's perception
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history of present illness: PQRST mnemonic
- Provocative or Palliative
- Quality or Quantity
- Region or Radiation
- Severity scale
- Timing
- Understand patient's perception
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review of systems
- skin, hair
- head, eyes, ears, nose, throat
- neck
- breast, axilla
- respiratory
- cardiovascular
- peripheral vascular
- gastrointestinal
- urinary
- genital, sexual health
- musculoskeletal
- neurologic
- hematologic
-
functional assessment
- self-esteem, self-concept
- activity, exercise
- sleep, rest
- nutrition, elimination
- interpersonal relationships, resources
- spiritual resources
- coping, stress management
- personal habits
- alcohol, street drugs
- environment, hazards
- intimate partner violence
- occupational health
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