Chapter 2. Patient Assessment

2.2 Health History

The purpose of obtaining a health history is to gather data from the patient and/or the patient’s family, so the healthcare team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital or a care agency, or with initial contact with community nursing services, but a health history may be taken whenever additional information may be helpful to inform care (Wilson & Giddens, 2013).

Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include symptoms described by the patient that are not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Checklist 13 provides a guide for obtaining subjective data during a health history.

It should be noted that the theoretical underpinnings of the different components of a health history are beyond the scope of this textbook. However, the nurse should remember that using open-ended questions allows the patient to direct the interview and may reveal information otherwise missed through closed-ended questioning.

Objective data is information that the healthcare professional gathers during a physical examination and consists of information that can be seen, felt, smelled, and/or heard by the healthcare professional. When taking a health history, data obtained through diagnostic means (i.e., vital signs, blood work, chest x-ray, etc.) may be used by healthcare professionals to understand the client’s health status.

Critical thinking is necessary to interpret and evaluate the assessment findings, and to use this to inform nursing judgement. The data gathered in a health history provides the healthcare professional an opportunity to assess health promotion practices and offer patient education (Stephen, Skillen, Day, Jensen, 2012).

It should be noted that although agency forms may differ slightly, all health histories should include main components similar to the ones listed in Checklist 13.

Checklist 13: Health History Checklist

Disclaimer: Always review and follow your agency policy regarding this specific skill.


Additional Information

Biographical data
  • Source of information
  • Name, age, gender
  • Living situation
Chief complaint; history of present illness; reason for seeking health care
  • Chief complaint
  • Onset and duration of present health concern
  • What caused the health concern to occur?
  • Signs, symptoms, and related problems
  • Alleviating and aggravating factors
  • How the concern affects life and activities of daily living?
  • Previous history and episodes of this condition
Past health history
  • Allergies (including reaction)
  • Immunization history (if applicable)
  • Chronic disease(s)
  • Acute diseases requiring treatment
  • Previous hospitalizations
  • Previous surgical interventions
  • Mental health history
  • Current medications: prescriptions, over-the-counter, herbal remedies
  • Alcohol consumption and recreational drug use
  • History of antibiotic resistant organisms (ARO)
Social data
  • Reported quality of family or friend relationships
  • Cultural health-related beliefs and practices
  • Nutrition considerations related to culture
  • Social and community considerations: interpersonal relationships and resources; caregiver responsibilities
  • Religious or spiritual beliefs and practices
  • Language and ability to communicate
  • Pertinent health history of family members (heart disease, lung disease, cancer, hypertension, diabetes, tuberculosis, arthritis, neurological disease, obesity, mental illness, substance use and abuse, genetic disorders)
Lifestyle Personal habits including:

  • Activity and exercise
  • Leisure and recreational activities
  • Sleep and rest
  • Nutrition and elimination
  • Occupational and environmental hazards
Developmental variables
  • Relationship status
  • Significant physical and psychosocial changes or concerns
Mental status assessment
  • Stressors experienced by the individual: their perception, how they cope, ability to communicate emotion
  • Coping and stress management
Patterns of health care
  • What healthcare resources the client has used in the past and is currently using
Data sources: Assessment Skill Checklists, 2014; Lloyd & Craig, 2007; Potter et al., 2019

Critical Thinking Exercises

  1. Why is it important to obtain a complete description of the patient’s present illness?
  2. Identify one reason why it is important for the nurse to obtain a complete description of the client’s lifestyle and exercise habits?


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Clinical Procedures for Safer Patient Care Copyright © 2018 by Thompson Rivers University is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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