The Health History Assessment: A Comprehensive Guide

RUNNING HEAD: THE HEALTH HISTORY 1
The Health History
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THE HEALTH HISTORY 2
Health History assessment
INTRODUCTION
A health history assessment tool is a protocol that seeks to know specific requirements of
a patient and how they can be handled by the nurses (Ross et al., 2018). It can also be defined as
the evaluation of the health condition by carrying out a physical exam after getting a health
history (McCrae, 2015). Below is Health History assessment of a patient I interviewed.
Biographic data
M D is a 67 year old married white lady. At the moment, she has been unemployed for
close to four months. Her latest job was as a private home health assistant to a friend’s elderly
parents who unfortunately passed on. She worked at that place for seven months. M D was born
in Atalanta in a family of Mexican decent. However, she currently lives within the suburbs of
Atalanta and her primary language is English.
Perception of health
Generally D believes that she is healthy since she has never suffered from any chronic or
serious illness from childhood. Besides, she conducts regular visits to her private physician and
therefore there is no cause of alarm concerning her health.
Culture and spirituality
M D was raised as a Roman Catholic where politeness, table manners, praying before
meals, respect to the elderly, finishing her chores before engaging in recreation activities, sharing
and attending church service on every Sunday was necessary. She was also raised in a family

THE HEALTH HISTORY 3
where the Dad was the leader of the household though he made decisions on a mutual basis with
her mother. Besides, her parents did share different house chores as well.
Past medical history
M D has never suffered from any chronic infections at the moment and neither did she
have any serious infections while she was still a child. The only notable case however, was
chickenpox that she suffered from when she was about 4 years as well as shingles 19 years
ago.MD was as well hospitalized twice during childbirth and the obstetric results indicate
Gravida 3/term 3/preterm 0/Abortion 0/living. Out of the two childbirths, it was very unfortunate
that all of them were uncomplicated vaginal deliveries. Her surgical history is tubal ligation
when she was 20 and surgical expulsion of cysts in her right breast. With allergies, she has no
known allergy but her current over the counter drugs are 400-600 mg of ibuprofen that act as
painkillers.
Family medical History
M D did indicate that her father was a serial smoker and he was suffering from chronic
Obstructive Pulmonary up to his death. Her mother on the other hand was suffering from
hypertension up to her time of her death. Her two brothers and one sister are healthy and they
don’t have any significant health condition.
Review of systems.
M D did indicate that she is generally healthy with neither cardiac, urinary, respiratory
nor any gastrointestinal deformities. She also doesn’t have any history of skin diseases. There is
no current loss of hair. Her pupils react on light. She has no history of either glaucoma or
cataracts. Her head is norm cephalic and the ears are normal. She has no history of any chronic