Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Biographical Data
(name, address and phone number; age and birthday; birthplace; gender; marital status;
race; ethnic origin, occupation – both usual and present)
Source of History
(WHO: patient, parent, spouse, partner; RELIABILITY)
O: Onset: When did the problem first start? Setting and circumstances - chronologic sequence of events. Manner of
onset (Sudden vrs. Gradual) What was the person doing? What seems to bring on the symptoms?)
Review of Systems
Skin:
History of skin disease ____ ____
(eczema, psoriasis, hives)
Pigment or colour change ____ ____
Change in Mole ____ ____
Excessive dryness ____ ____
Excessive moisture ____ ____
Pruritis ____ ____
Excessive Bruising ____ ____
Rash ____ ____
Lesion ____ ____
Health Promotion: (sun exposure, self care for skin)
Hair: Yes No
Recent loss ____ ____
Change in texture ____ ____
Health Promotion: (self care for hair)
Nails:
Change in shape, colour or brittleness ____ ____
Head:
Unusually frequent or severe headache ____ ____
Any head injury ____ ____
Any dizziness(syncope) ____ ____
Any vertigo ____ ____
Neck:
Any Pain ____ ____
Any limitation of motion ____ ____
Any lumps or swelling ____ ____
Any enlarged or tender nodes ____ ____
Any goiter ____ ____
Eyes:
Difficulty with vision ____ ____
(decreased acuity, blurring, blind spots)
Any eye pain ____ ____
Diplopia or double vision ____ ____
Any redness or swelling ____ ____
Any watering or discharge ____ ____
Glaucoma ____ ____
Cataracts ____ ____
Health promotion: Wearing of glasses or contacts; last vision check or glaucoma check, how is individual coping
with any vision loss?
Ears: Yes No
Earaches ____ ____
Infections ____ ____
Discharge ____ ____
Tinnitus ____ ____
Vertigo ____ ____
Health promotion: Hearing loss(how loss affects daily life, hearing aid use), exposure to environmental noise,
method of cleaning ears)
Health Promotion: pattern of daily dental care; use of prostheses (dentures, bridge), and last dental checkup.
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Hemoptysis _____ _____
Toxin or Pollution Exposure _____ _____
Cardiovascular System:
Peripheral Vascular:
Health Promotion:
Does work involve long term sitting, standing? Wearing of support hose? Avoiding crossing of legs?
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Stool characteristics
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Health Promotion: measures to avoid or treat urinary tract infections, use of Kegel exercises
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Male:
Penile or testicular pain _____ _____
Sores or lesions _____ _____
Penile discharge _____ _____
Lumps _____ _____
Hernia _____ _____
Female:
Menstrual history
Age of menarche _____________________
Last menstrual period, cycle and duration _________________________________________
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Amenorrhea _____ _____
Menorrhagia _____ _____
Premenstrual pain or dysmenorrhea _____ _____
Yes No
Intermenstrual spotting _____ _____
Vaginal itching _____ _____
Vaginal discharge _____ _____
Characteristics of vaginal discharge _________________________________________________
Age at menopause ___________________________
Health Promotion:
Performs breast self exam; include frequency and method used. Date of last mammogram.
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Sexual History:
Any known or suspected contact with a partner who has a sexually transmitted disease(gonorrhea, herpes,
chlamydia, venereal warts, AIDS or syphilis) ______ ______
Health Promotion: How much walking per day? What is effect of limited range of motion on ADL’s such as
grooming, feeding, toileting, dressing? Any mobility aids used?
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Motor function:
Any weakness, tic or tremor _____ _____
Any paralysis or coordination problems _____ _____
Sensory function:
Any numbness and tingling(parathesia) _____ _____
Cognitive function:
Any recent memory disorder _____ _____
Any disorientation _____ _____
Mental Status:
Nervousness _____ _____
Mood change _____ _____
Depression _____ _____
History of mental health dysfunction or hallucinations _____ _____
Describe:_______________________________________________________________________
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Endocrine System:
Religious preferences (Faith: Does religious faith or spirituality play an important role
in your life?
Influence: How does your religious faith or spirituality influence the way you think
about your health or way you care for yourself?
Community: Are you a part of any religious or spiritual community or congregation?
Address: Would you like me (the health care professional) to address any religious or
spiritual issues or concerns with you?)
Self-Esteem, Self-Concept
General life satisfaction, hobbies, interests
Education: last grade completed, other significant training;
Financial status: income adequate for lifestyle and/or health concerns;
Value-belief system: religious practices and perception of personal strengths)
Personal Habits:
(Tobacco: Do you smoke? cigarettes, pipe, chewing tobacco? At what age did you start?
How many packs per day? How many years? If stopped, how long since stopped and the
same questions asked for the time they were a smoker. If they have tried to quit, what
did they try? How did it go? Which leads into smoking cessation discussion.)
Alcohol: Do you drink alcohol? When was your last drink? How much do you drink each
day, each week? If patient answers ‘no’ to drinking alcohol ask the reason for this
decision. Any history of drinking alcohol? Any history of treatment? Involvement in
recovery activities? History of family member with problem drinking?
Street Drugs: Ask specifically about marijuana, cocaine, crack cocaine, amphetamines,
and barbiturates. Indicate frequency of use and how use has affected work and family.)
Sleep/Rest
(Sleep patterns, daytime naps, any sleep aids used)
Nutrition/Elimination
(Record the diet recall for 24-hour period. Is this menu typical? Who buys and prepares
food? Finances? Who is present at meal times? Food allergy or intolerance. Daily intake
of caffeine (coffee, tea, cola drinks). Usual patterns for bowel elimination and urinating.
Aids used for mobility or transfer in toileting. Any continence issues or use of laxatives.)
Environment/Hazards
Home, school, work.(Where do they live? With whom? Do they know their neighbours and the
neighbourhood? Safety of the area? Adequate heat and utilities? Access to
transportation? Involved in the community? Note environmental health, hazards
in the workplace and the home? Use of seat belts? Geographic or occupational
hazards (time spent abroad for travel or work)?)
Occupational Health
Work conditions and hours. Physical and mental strain; Work with any health
hazards (asbestos, inhalants, chemicals, repetitive motion.) Protective devices used. Any
programs at work designed to monitor your exposure? Any health problems you think are
related to your job? What doyou like or dislike about your job?)
Reference
Jarvis, C. (2008). Physical examination and health assessment (5th ed.). Philadelphia:
W.B. Saunders.