MN552 Advanced Health Assessment
Unit 2 Documenting Subjective information
History and Interview
Please select a volunteer friend or family member to interview and gather data to
complete this Assignment. The following guide will assist you in gathering subjective
data in an organized, systematic manner to prevent omission of important components
of the health history.
Date of History/Interview:
Source of history and Reliability:
Biographical Data
a. Name (use initials only)
b. Primary language
c. Age and Date of Birth
d. Place of Birth
e. Gender
f. Race
g. Marital Status
h. Ethnic/Cultural Origin
i. Education ( highest level completed)
j. Occupation/Professional
k. Health insurance (ie commercial, state, federal)
2. Chief Complaint (reason for seeking health care):
a. Brief spontaneous statement in client’s own words
b. Includes when the problem started ( “chest pain for 2 hours”)
3. History of Present Illness: A well organized, chronological record of client’s reason
for seeking care, from time of onset to present. Please include the 8 critical
characteristics using the OLD CARTS pneumonic.
P – Provocative or palliative (What brings it on? What makes it better or worse?)
, Q – Quality or quantity (Describe the character and location of the symptoms;
How does it look, feel, sound?)
R – Region or radiation (Where is it? Does the symptom radiate to other areas of
the body?).
S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10).
T – Timing (Inquire about time of onset, duration, frequency, etc.)
U – Understand Patient’s Perception of the problem (What do you think it
means?)
** Put all of that information into the heading HPI in a story format.
4. Past Medical History (list down not across)
a. Medical Hx: major illnesses during life span, injuries, hospitalizations,
transfusions, and disabilities
b. Childhood Illnesses: Measles, mumps, rubella, chickenpox, pertussis, strep
throat
c. Surgical Hx; procedures, dates, inpatient or outpatient
d. Obstetric HX: Number of pregnancies, term deliveries, preterm births,
abortions
(spontaneous or induced), number of children living
e. Immunizations
f. Psychiatric Hx: childhood and adult (treated or hx of)
g. Allergies: Medications, food, inhalants or other (what occurs with reaction)
h. Current Medications: Include all prescription, herbal/supplements and OTC,
dosage, frequency
i. Last Examination Date: Physical, eye exam, foot exam, dental exam, hearing
screen, EKG, chest X-Ray, Pap test, mammogram, serum cholesterol, stool
occult blood, prostate, PSA, UA, TB skin test; other health maintenance tests
for infants/children may include sickle-cell, PKU, lead level, and hematocrit
5. Family History list FHx
a. Include parents, grandparents, spouse, and children.
b. Health conditions, familial and communicable diseases/illnesses
c. Note whether family member deceased or living
II. Life style patterns
a. Immigrant status
b. Spiritual resources/religion
