An initial observation is what you observe using your senses of sight, smell, and hearing upon your initial encounter with the patient. The ability to transfer that observation to written form takes practice. Remember, you are painting a picture of the patient. That will enable someone else to visualize that patient after reading the initial observation. Be as descriptive as possible. Referring to the vocabulary sheet if necessary.
Items to include:
Age: Not the number of years. Instead use categories: infant, toddler, school aged child, preteen, teenager, young adult, middle-aged adult, older adult
Build: Slight, medium, or large
Sex: Male or female
Setting: This describes the surroundings you found your patient in. Please include location, temperature of the room, lighting in the room, location of the patient in the room, organization of the room, and items present in surroundings
Skin and nails: Color and condition
Hair: Color and condition
Clothing: Is it appropriate for season or temperature? Is it matching? Is it clean?
Cognitive ability: Speech clarity, hearing ability, eye contact, appropriateness of speech.
Behavior: Pleasant, cooperative, agitated, or angry.
Noise: Are there any noises present either from the patient or in the surroundings, labored breathing, medical equipment, etc.?
Odors: Any odors present either regarding the patient or surrounding? Urine odor noted. Floral, perfume noted, etc.
Health History Form w/example questions
Interviewer: ____________________________________ Patient Initials: __________________
Client Description: age, sex, race, size, height, weight
Initial Observation: see Initial Observation page
Chief Concern: what is your major health problem? What caused you to seek health care?
History of Present Illness:
S (start) When did it first start?
W (worse) What makes it worse?
I (improve) What makes it better?
P (pattern) Does it occur at specific times?
E (evaluation) What is the current treatment and is it working?
Past History: General Health/Allergies.
Medication and Substance use: What medications do you use? And in the past?
Do you take over the counter medications?
How much alcohol do you drink on average?
Do you take any herbal supplements/natural remedies?
Do you smoke cigarettes or marijuana?
Have you ever used illicit drugs?
Any other diseases
Any accidents or injuries
Ever been treated for mental/emotional problems
Family Medical History: Disease or condition they have or cause of death
Who do you live with? Describe your family.
Who is the most important person in your life?
Are you close to your extended family?
Do you have any pets?
What do you do for fun and relaxation?
Are you involved in your community?
Self-concept: What are your strengths and weaknesses?
How do you feel about yourself, Your appearance?
Value or belief system:
What is the most important to you in life?
Do you have a religious affiliation?
What gives you strength and hope?
Stress levels and coping styles:
Is your work/school stressful?
What makes you angry?
What do you see as the greatest stressors in your life?
Where do you turn for help in times of crisis?
Lifestyle assessment: Description of a typical day
Nutritional habit: What do you usually eat during a typical day?
What foods do you prefer?
Do you eat at restaurants frequently?
Do you buy and prepare your own food?
Do you eat alone?
How much and what types of fluids do you drink?
Elimination pattern: Frequency of voiding? How much and how often?
Color Description, Frequency of BMs, Constipation, Diarrhea?
What is your daily pattern of activity?
Do you follow a regular exercise plan?
Any reasons you could not follow an exercise plan?
What do you do for leisure or recreation?
Are you able to care for yourself? Bathing, dressing, etc.
Tell me about your sleeping pattern.
Do you have trouble getting to sleep or staying asleep?
How much sleep do you get?
Do you nap during the day?
Health practices and maintenance:
What do you do to keep yourself healthy?
Do you practice self breast/testicular exam?
Are vaccinations up to date?
Do you understand your illness and your medications?
Have you fallen recently?
Do you feel your environment is safe?
Review of systems: Patient perspective of the following systems.
Have you had a problem with:
Skin, hair, nails: Color, balding, sweating, rashes
Head and neck: Stiffness, swallowing, sore throat
Eyes and ears: Vision, blurring, spots, double vision, eye pain, halos around light, ringing in ears, drainage, dizziness, aches
Mouth, throat, nose, and sinuses: Teeth or gum problems, hoarseness, runny nose, frequent colds, nosebleeds, snoring
Thorax and lungs: Difficulty breathing, shortness of breath, shortness of breath with activity, orthopnea, cough
Breasts: Lumps, discharge, tenderness, nodes in axilla
Heart and neck vessels: Chest pain, pressure, palpitations, edema
Abdomen: Nausea, vomiting, pain, gas, heartburn, indigestion
Genitalia: Bladder- Painful or excessive urination, difficulty starting or leaking of urine, color of urine, incontinence, menarchy, menstruation, pregnancy, problems with menopause, use of hormone replacement
Anus, Rectum: Bowel habits, pain, hemorrhoids, blood in stool, constipation, diarrhea
Peripheral vascular: Swelling or edema of legs and feet, pain, cramping, sores on legs.
Musculoskeletal: Stiffness of joints. ability to perform ADLs, swelling, redness, pain
Neurological: General mood, behavior, depression, anger, concussion, headache, loss of strength or sensation, difficulty speaking, memory problems