Essay on Identifying The Components Of A Client 's Health History

1865 Words Sep 23rd, 2016 8 Pages
2. Identify the components included in a client’s health history.
Biographic Data-The client’s demographic data, should include the name, address, age, sex, marital status, occupation, religion, health care financing, and their primary care provider.
Chief Complaint-The reason for the visit should be obtained and documented in the client’s own words.
History of Present Illness-Gather more information about the present illness by asking questions such as: When did the symptoms start? Did it occur suddenly or gradually or increased over time? How often does the problem occur? What is the intensity of the pain? Can you rate it from 0 to 10? How much sputum, vomit, or discharge came up or out? What color was it? Was it watery, thick, or bloody? Were you participating in any activities when the problem occurred? Are there any other symptoms associated with this problem? Is there anything that makes the problem worse? Is there anything that makes the problems better?
Past Medical History- Any significant illnesses such as chickenpox, hepatitis, and polio should be obtained, as well as, immunizations and date of last tetanus. You should question the client about their allergies to medication, drugs, foods. animals, insects, or environmental agents. Along with that, document the kind of reaction that occurred and the treatment for the reaction. In addition, any accidents or injuries should be recorded. Ask the client: What kind of injury occurred? How, when, and where did it…

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