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29 Cards in this Set
- Front
- Back
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Biographical Data
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Name
Address Phone Number Age Birth Date Birthplace Gender Martial Status Ethnocultural Background Occupation |
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Source of History
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-Who gives you the information (patient, family, friend)
-How reliable (rephrase questions) -Special Circumstances (interpretor) |
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Reason for Seeking Care
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Statement given by patient involving one sign or symptom
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Symptom
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Subjective sensation that the person feels
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Sign
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Objective abnormality that the assesser can detect
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Present Health or History
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Location, Quality (burning, sharp, dull), Severity, Timing, Setting, Aggrevating and Relieving factors, Patients perception
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P
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P: Provocative- What were you doing when it occured
-What brings it on -What makes it better/ worse |
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Q
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Quality/Quantity
-How does it look, feel sound -How intense/severe |
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R
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Region or Radiation
-Where is it -Does it spread |
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S
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Severity Scale
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T
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Timing: When did it occur
How long does it last Constant/ Intermittant |
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U
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Understand patients perception of the problem
-What do you think it means. |
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Past Health
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-Childhood Illnesses
-Accidents/ Injuries -Serious/ Chronic Illnesses -Hospitalizations -Operations -Obsterical History -Immunizations -Last Examin date -Allergies -Current Medications |
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Family History
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-Age and health of relatives
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Functional Assessment
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Provide Data on the Lifestyle and Type of Living Environment
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1. Self Esteem/ Concept
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Education
Financial Status Value Belief System (religious) |
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2. Activity and Mobility
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Usual Daily Tasks:
-Ask how do you spend a typical day -Note the ability to preform ADL's -Record leisure activities and exercise pattern |
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3. Sleep and rest
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-Sleep patterns
-Daytime naps -Any sleeping aids used |
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4. Nutrition and Elimination
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Do a 24 hour dietary recall
-Ask about pattern of elimination and urinating |
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5.Interpersonal Relationships
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-role in the family
-do you have support from family |
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6. Spiritual Resources
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F: Faith-religious indiv?
I: Influence- think about health C:Community-congregation A: Address- any religious or religious or spiritual issues |
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7. Coping and Stress Management
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-How do you cope with stress
-What kind of stress -What causes stress |
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8. Smoking
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-How long have you smoked
-How many packs a day -At what age did you start -Have you ever tried to quit |
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9. Alcohol
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-Amount and Frequency
-Out of the last 30 days how many did you drink alcohol |
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CAGE test
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C: Have you ever though you should cut down
A:Annoyed by criticism of your drinking G:Guilty about your drinking E:Do you drink in the morning (eye-opener) If answers yes to two or more: alcohol abuse |
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10. Drug Use
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-Frequency
-What they use -How it affects work or family |
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11. Enviromental Hazards
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-Safety of area
-Heat and utilities -Access to transportation -Involved in community |
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12. Intimate Partner Violence
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-How are things at home
-Is your home safe |
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13. Occupational Health
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-Describe his/her job
-Ever work with health hazard -Do you wear protective equipt |
