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Identifying The Components Of A Client 's Health History

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1. 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 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 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? …show more content…

Moreover, diseases that require particular attention includes: heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism, and mental health disorders. Lifestyles-Ask the client about their personal habits such as the amount of tobacco, alcohol, caffeine, or recreational drugs consumed. Also, obtain their normal daily diets, special diets, or ethnic food patterns; and the amount of meals and snacks per day. Likewise, who cooks and do the shopping? In addition, ask about the client’s sleep pattern. What time do you go to bed/ what time do you wake up? Any you having any problems sleeping? Have you tried anything to correct this problem? Furthermore, ask about the daily living activities. Are you having any problems performing basic activities such as eating, grooming, dressing, elimination, or locomotion? Are you having any problems with preparing foods, shopping, transportation, housekeeping, laundry, or the ability to use the telephone, handle finances, or manage your medication. Finally, ask the client do you exercise and how well do you tolerate the activity? Do you have any other hobbies? Social Data-Ask the client who helps them during times of stress? What effects have your illnesses had on the family and are there any family problems affecting your illness? Do you have any religion or beliefs that could affect your health or recovery? Moreover, find out about the client’s education. What is

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