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1. Otterbein University Graduate Studies in Nursing, Nursing 6830 –Spring
2021 Tina Jones Comprehensive Health History Write-up Assignment
Otterbein University Graduate Studies in Nursing, Nursing 6830 –Spring 2021 Tina Jones
Comprehensive Health History Write-up AssignmentTina Jones Comprehensive Health
History Write-up AssignmentAppendix CComprehensive Health History Take the
information from the Shadow Health Health History and place in this
format Comprehensive Adult Health History (taken from Bickley, 2017)PROBLEM
LISTActive problems Inactive problemsIII. Risk factors COMPREHENSIVE HISTORY
(Subjective Data) – Date & TimeORDER NOW FOR WELL-WRITTEN, PLAGIARISM-FREE
ASSIGNMENTClient Identifying data (initials only!)May include age, gender, occupation,
marital statusSource of data – (most often the patient, can be a family member or friend, the
medical record, etc)Reliability- include if relevant Chief complaint(s) /presenting
problemOne or more symptoms or concerns causing the patient to seek care; be brief and
try to quote patient’s own words PI (History of Presenting Illness)Complete, clear and
chronological account of the problems prompting the patient to seek care. Include 1)
location; 2) quality or character; 3)quantity or severity; 4) timing, including onset, duration
and frequency; 5) the setting in which it occurs; 6) factors that have aggravated or relieved
the symptoms; and 7) associated symptoms. Include pertinent positives and negatives
from the section of the Review of Systems related to the Chief Complaint. These include the
presence or absence of symptoms relevant to the differential diagnosis. (some find the
OLDCARTS mnemonic helpful, Tina Jones Comprehensive Health History Write-up
Assignment) Include other relevant information – such as risk factors for CAD in patients
with chest pain.Include the response to the symptoms and the effect the illness has had on
the patient’s life.Other symptoms or concerns need a separate description and
paragraph.(This needs to be written in chronological order, describe the current episode
and then from the onset until now) Medications – Note name, dose, route, frequency.
Include OTC, herbal, vitamins and minerals, inhalers, ear and eye medications Allergies –
include specific reactions to medications, such as rash, and allergies to food, insects or
environmental factorsTobacco Use – report cigarettes in pack years. Note how long
someone has quit.Alcohol and Drug use Past Medical History Childhood
IllnessesInclude: measles, rubella, mumps, pertussis or whooping cough, chicken pox,
rheumatic fever, scarlet fever, polio, and any chronic childhood illnesses Adult
IllnessesMedical: Illnesses such as diabetes, hypertension, hepatitis, asthma,

2. HIV,Hospitalizations: dates and reasonSurgical: Dates, indications, type of surgery,
outcomesOB/GYN/Sexual history-pregnancies, births, miscarriages/AB , menstrual history,
methods of contraception, sexual function, number and gender of sexual partners, safe sex
practicesPsychiatric: Illnesses and time frame, diagnoses, hospitalizations and
treatmentsHealth Maintenance- immunizations –vaccines for tetanus, pertussis, diphtheria,
polio, measles, rubella, mumps, influenza, varicella, hepatitis B, Haemophilus influenzae
type B, pneumococci, and herpes zoster.Screening tests – Tb tests, pap smears,
mammograms, stool for occult blood, colonoscopy, cholesterol – results and last
performed.Family HistoryCreate a genogram –Include age, health or cause of death, of
immediate family members (parents, grandparents, siblings, children and
grandchildren).Ask about each of the following conditions and record whether they are
present or absent in the family: hypertension, coronary artery disease, elevated cholesterol
levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung
disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies.
Ask about any history of breast, ovarian, colon or prostate cancer, and any genetically
transmitted diseases. Personal and Social HistoryIncludes occupation, education, home
situation, significant others, sources of stress, important life experiences, leisure activities,
religious affiliation and spiritual beliefs, and activities of daily living (ADLs), lifestyle
habits: exercise, diet, usual daily food intake, dietary supplements or restrictions, use of
coffee, tea and other caffeinated beverages, sleep habits, safety measures such as use of seat
belts, bicycle helmets, sun block, smoke detectors. Include alternative health care
practices Review of systems General: usual weight, recent weight change, clothing
fits more tightly or loosely than before, weakness, fatigue, fever Skin: rashes, lumps, sores,
itching, dryness, color changes, changes in hair or nails, changes in size or color of
moles Head: headaches, head injury, dizziness, lightheadedness Eyes: vision, glasses or
contact lenses, last eye exam, pain, redness, excessive tearing, double vision, blurred vision,
spots, specks, flashing lights, glaucoma, cataracts Ears: Hearing, tinnitus, vertigo, earaches,
infections, discharge, hearing aids Nose/sinuses: frequent colds, nasal stuffiness, discharge,
itching, hay fever, nosebleeds, sinus trouble Throat: Condition of teeth, gums, bleeding
gums, dentures/fit, last dental exam, sore tongue, dry mouth, frequent sore throats,
hoarseness Neck: swollen glands, goiter, lumps, pain, or stiffness in neck Breasts: lumps,
pain or discomfort, nipple discharge, self-exam practices Respiratory: cough, sputum
(color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last CXR Cardiac: heart trouble,
high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations,
dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, ECG or other cardiac
tests GI: trouble swallowing, heartburn, appetite, nausea, vomiting, bowel movements,
stool color and size, change in bowel habits, pain with defecation, rectal bleeding, or black
or tarry stools, hemorrhoids, constipation or diarrhea, abdominal pain, food intolerance,
excess belching or passing gas, jaundice, liver or gallbladder, problems, hepatitis Peripheral
vascular: intermittent claudication, leg cramps, varicose veins, past clots in veins, swelling
in calves, legs or feet, color change in fingertips or toes during cold weather, swelling with
redness or tenderness Urinary: frequency of urination, polyuria, nocturia, urgency, burning
or pain during urination, hematuria, urinary infections, kidney or flank pain, kidney stones,

3. ureteral colic, suprapubic pain, incontinence; for men: reduced caliber or force of the
urinary stream, hesitancy, dribbling Genital: Male: hernias, discharge from or sores on
penis, testicular pain or masses, scrotal pain or swelling, history of sexual transmitted
infections and their treatment, sexual habits, interest, function, satisfaction, birth control
methods, condom use, and problems, concern about HIV infection Female: Age at menarche,
regularity, frequency and duration of periods, amount of bleeding, bleeding between
periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual
tension, age at menopause, menopausal symptoms, postmenopausal bleeding, exposure to
DES (if born before 1971). Vaginal discharge, itching, sores, lumps, sexually transmitted
infections and treatments. Number of pregnancies, number and type of deliveries, number
of abortions, complications of pregnancy, birth control methods. Sexual preference, interest,
function, satisfaction any problems including dyspareunia, concerns about HIV
infection Musculoskeletal: muscle or joint pain, stiffness, arthritis, gout, backache, neck
paint. If present, describe location of affected joints or muscles, any swelling, redness, pain,
tenderness, stiffness, weakness or limitation of motion or activity. Joint pain with systemic
features such as fever, chills, rash, anorexia, weight loss, or
weakness Psychiatric: Nervousness, tension, mood, including depression, memory change,
suicide attempts, if relevant Neurologic: Changes in mood, attention or speech, change in
orientation, memory or insight, or judgment, headache, dizziness, vertigo, fainting,
blackouts, weakness, paralysis, numbness or loss of sensation, tingling, or “pins and
needles”, tremors, or other involuntary movements, seizures Hematologic: anemia, easy
bruising or bleeding, past transfusions, transfusion reactions Endocrine: “thyroid trouble”,
heat or cold intolerance, excess sweating, excess thirst or hunger, polyuria, change in glove
or shoe sizeAppendix C (continued)Grading Rubric: Comprehensive Adult Health History
Partial points Partial points Full pointsChief Complaint Both not a quote and
too wordy (0) Either not a quote or too wordy (1) In patient’s own words & concise,
time frame if appropriate (2 points )HPI Missing > one component of HPI, not
chronological or coherent (1-3) Missing one component of HPI, or missing significant
positives and negatives (4) Chronological, includes 7 components, includes significant
positives and negatives (5)Medications, Allergies, LMP Missing at least one
component (0) Includes names of Meds, Allergies and LMP but missing other details(1)
Includes all medications, reason for meds, how taken; allergies to medications,
environmental factors and food, and how allergies are manifest; includes LMP if
childbearing age (2)PMH Missing more than one component (1-2) Missing one or
more component, or component not complete (3) Includes all components: childhood
Illnesses, Adult illnesses, (Medical, Hospitalizations, Surgeries, OB/GYN hx, Psych,
Accidents, Health Maintenance) Includes negatives for major illnesses (4)Family History
Missing > one component(1) Missing one component or component not complete
(2) Includes genogram with parents, grandparents, children and major significant
chronic illness; asks about illnesses listed in Bates for FH (3)Personal Social History
Missing > one component (1) Missing one component or component not complete
(2) Includes all of the categories listed in the Adult Health History Sheet (3) Tina Jones
Comprehensive Health History Write-up AssignmentReview of Systems Missing > one

4. component (1-3) Missing one component or component not complete (4)
Includes 20 systems as laid out in Bates, includes important negatives at least to the
detail in chapter 2 in text (5)Problem List Missing >1 problem(1)Problem list missing
an important problem (2) Problem list appropriate and complete based on history
(3)Overall Unclear in several sections, not well organized (1) Mostly well organized
and clear (2) Well organized, easy to read and follow, typed (3)Tina Jones Comprehensive
Health History Write-up Assignment