The health history is a current collection of organized information unique to an individual. Relevant aspects of the history include biographical, demographic,
Holistic— Pertaining to all aspects of the patient, including biological, psychosocial, and cultural factors.
Subjective— Influenced by the perspective of the information provider; potentially biased.
physical, mental, emotional, sociocultural, sexual, and spiritual data.
The health history aids both individuals and health care providers by supplying essential information that will assist with diagnosis, treatment decisions, and establishment of trust and rapport between lay persons and medical professionals. The information also helps determine an individual’s baseline, or what is normal and expected for that person.
Every person should have a thorough health history recorded as a component of a periodic physical examination. These occur frequently (monthly at first) in infants and gradually reach a frequency of once per year for adolescents and adults.
The clinical interview is the most common method for obtaining a health history. When a person or a designated representative can communicate effectively, the clinical interview is a valuable means for obtaining information.
The information that comprises the health history may be obtained from a person’s previous records, the individual, or, in some cases, significant others or caretakers. The depth and length of the history-taking process is affected by factors such as the purpose of the visit, the urgency of the complaint or condition, the person’s willingness or ability to contribute information, and the environment in which information is sought. When circumstances allow, a history may be holistic and comprehensive, but at times only a cursory review of the most pertinent facts is possible. In cases where the history-gathering process needs to be abbreviated, the history focuses on a person’s medical experiences.
Health histories can be organized in a variety of ways. Often a hospital or clinic will provide a form, template, or computer database that serves as a guide and documentation tool for the history. Generally, the first aspect covered by the history is identifying data.
Identifying or basic demographic data includes facts such as:
- date of birth;
- family structure or living arrangements; and
- source of referral.
Once the basic identifying data is collected, the history addresses the reason for the current visit in expanded detail. The reason for the visit is sometimes referred to as the chief complaint or the presenting complaint. Once the reason for the visit is established, additional data is solicited by asking for details that provide a more complete picture of the current clinical situation. For example, in the case of pain, aspects such as location, duration, intensity, precipitating factors, aggravating factors, relieving factors, and associated symptoms should be recorded. The full picture or story that accompanies the chief complaint is often referred to as the history of present illness (HPI).
The review of systems is a useful method for gathering medical information in an orderly fashion. This review is a series of questions about the person’s current and past medical experiences. It usually proceeds from general to specific information. A thorough record of relevant dates is important in determining relevance of past illnesses or events to the current condition. A review of systems typically follows a head-to-toe order.
The names for categories in the review of systems may vary, but generally consists of variations on the following list:
- head, eyes, ears, nose, throat (HEENT);
- integumentary (skin);
- musculoskeletal, including joints;
- nervous system, including both central and peripheral components; and
- mental, including psychiatric issues.
Past and current medical history includes details on medicines taken by the person, as well as allergies, illness, hospitalizations, procedures, pregnancies, environmental factors such as exposure to chemicals, toxins, or carcinogens, and health maintenance habits such as breast or testicular self-examination or immunizations.
An example of a series of questions might include the following:
- How are your ears?
- Are you having any trouble hearing?
- Have you ever had any trouble with your ears or with your hearing?
If an individual indicates a history of auditory difficulties, this would prompt further questions about medicines, surgeries, procedures, or associated problems related to the current or past condition.
In addition to identifying data, chief complaint, and review of systems, a comprehensive health history also includes factors such as a person’s family and social life, family medical history, mental or emotional illnesses or stressors, detrimental or beneficial habits such as smoking or exercise, and aspects of culture, sexuality, and spirituality that are relevant to each individual. The clinicians also tailor their interviewing style to the age, culture, educational level, and attitudes of the persons being interviewed.
The information obtained from the interview is subjective, therefore, it is important that the interviewer assess the person’s level of understanding, education, communication skills, potential biases, or other information that may affect accurate communication. Thorough training and practice in techniques of interviewing such as asking open-ended questions, listening effectively, and approaching sensitive topics such as substance abuse, chemical dependency, domestic violence, or sexual practices assists a clinician in obtaining the maximum amount of information without upsetting the person being questioned or disrupting the interview. The interview should be preceded by a review of the chart and an introduction by the clinician. The health care professional should explain the scope and purpose of the interview and provide privacy for the person being interviewed. Others should only be present with the person’s consent.
Once a health history has been completed, the person being queried and the examiner should review the relevant findings. A health professional should
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
A health history is best obtained by a physician who has the training to appreciate nuances and details that may be overlooked by those with less training. Other health care professionals such as physician assistants and nurse practitioners have similar but somewhat limited training. Health histories are usually obtained in professional offices or hospitals. Occasionally, they are obtained in private homes or in the field.
discuss any recommendations for treatment or follow-up visits. Suggestions or special instructions should be put in writing. This is also an opportunity for persons to ask any remaining questions about their own health concerns.
There are virtually no risks associated with obtaining a health history. Only information is exchanged. The risk is potential embarrassment if confidential details are inappropriately distributed. Occasionally, a useful piece of information or data may be overlooked. In a sense, complications may arise from the findings of a health history. These usually trigger further investigations or initiate treatment. They are usually far more beneficial than negative as they often begin a process of treatment and recovery.
Normal results of a health history correspond to the appearance and normal functioning of the body. Abnormal results of a health history include any findings that indicate the presence of a disorder, disease, or underlying condition.
Disease and disability are identified during the course of obtaining a health history. There are virtually no risks associated with the verbal exchange of information.
There are no alternatives that are as effective as obtaining a complete health history. The only real alternative is to skip the history. This allows disease
QUESTIONS TO ASK THE DOCTOR
- What are your interpretations of my history, both normal and abnormal?
- What has changed since the last health history was obtained?
- What do you recommend as a result of your interpretation of the information obtained in this health history?
- When do you want to repeat the health history?
and other pathologic or degenerative processes to go undetected. In the long run, this is not conducive to optimal health.
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American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS, 66211-2672, (913) 906-6000, http://www.aafp.org.
American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA, 19106-1572, (215) 351-2400, (800) 523-1546, http://www.acponline.org.
L. Fleming Fallon, Jr., M.D., Dr.P.H.