An adult health history is a comprehensive assessment that provides essential information about a patient’s health status and informs medical decision-making. The components of an adult health history typically include the following sections:
1. Identifying Information
- Demographics: Patient’s name, age, gender, race/ethnicity, marital status, and contact information.
- Occupation: Current job and any relevant occupational history that may affect health (e.g., exposure to toxins).
2. Chief Complaint
- A concise statement describing the primary reason the patient is seeking medical care. It should be in the patient’s own words, if possible.
- Example: “I’ve been having chest pain for the last two days.”
3. History of Present Illness (HPI)
- A detailed exploration of the chief complaint, including:
- Onset: When did the symptoms start?
- Location: Where is the discomfort or issue located?
- Duration: How long has the patient been experiencing symptoms?
- Characteristics: What does the pain or symptom feel like (sharp, dull, throbbing)?
- Aggravating/Relieving Factors: What makes the symptoms worse or better?
- Associated Symptoms: Are there any other symptoms accompanying the chief complaint?
4. Past Medical History
- A comprehensive review of the patient’s past medical conditions, surgeries, and hospitalizations.
- Example: Chronic illnesses (e.g., diabetes, hypertension), previous surgeries (e.g., appendectomy), and hospital admissions.
5. Medication History
- A list of current and past medications, including prescriptions, over-the-counter drugs, supplements, and herbal remedies.
- Include information about dosage, frequency, duration of use, and adherence.
- Example: “Currently taking lisinopril 10 mg daily for high blood pressure.”
6. Allergies
- Documentation of any known allergies, including medications, foods, environmental factors, and the nature of the allergic reactions.
- Example: “Allergic to penicillin; causes hives.”
7. Family History
- A review of health conditions and diseases present in immediate family members (parents, siblings, children) that may have hereditary implications.
- Example: “Mother had breast cancer; father had diabetes.”
8. Social History
- An assessment of lifestyle factors that may affect health, including:
- Tobacco Use: Current and past smoking habits.
- Alcohol Consumption: Frequency and amount of alcohol intake.
- Illicit Drug Use: Any current or past use of recreational drugs.
- Physical Activity: Exercise habits and activity level.
- Dietary Habits: General eating patterns and nutrition.
- Living Situation: Housing stability, support systems, and environmental factors.
9. Review of Systems (ROS)
- A systematic review of each body system to identify any additional symptoms or issues not previously mentioned. This section can help uncover underlying health problems.
- Common systems include:
- General: Weight changes, fatigue, fever.
- Cardiovascular: Chest pain, palpitations, swelling.
- Respiratory: Shortness of breath, cough, wheezing.
- Gastrointestinal: Nausea, vomiting, diarrhea, constipation.
- Neurological: Headaches, dizziness, changes in vision.
- Musculoskeletal: Joint pain, stiffness, swelling.
10. Functional Assessment
- Evaluation of the patient’s ability to perform daily activities and overall functional status, including:
- Activities of Daily Living (ADLs): Basic tasks such as bathing, dressing, eating, and toileting.
- Instrumental Activities of Daily Living (IADLs): More complex tasks like managing finances, transportation, and medication management.
Summary
An adult health history is a vital component of patient assessment, encompassing various aspects of an individual’s health, medical history, and lifestyle factors. Collecting this comprehensive information enables healthcare providers to create effective treatment plans, make informed clinical decisions, and provide holistic care tailored to the patient’s needs.