Review of Systems (Health History)*
Name:__________________________________________________
Age:_______ DOB:________ Sex:_____ Race:_____________
Admission date:_________ Time:_________ From:__________
Source of information:______________ Reliability (1—4):______
Family member/Significant other:______________________________
Activity/Rest
Occupation:____________ Usual activities/Hobbies:__________
Leisure time activities:_____________________________________
Complaints of boredom:___________________________________
Limitations imposed by condition:___________________________
Sleep: Hours:__________ Naps:__________ Aids:__________
Insomnia:_________________ Related to:_________________
Rested upon awakening:___________________________________
Circulation
History of: Hypertension:_________ Heart trouble:___________
Rheumatic fever:_______ Ankle/leg edema:_______
Phlebitis:____________ Slow Healing:____________
Claudication:_____________ Other:_____________
Extremities: Numbness:_____________ Tingling:_____________
Cough/hemoptysis:___________________________________________
Change in frequency/amount of urine:________________________
Report of stress factors:_____________________________________
Ways of handling stress:_____________________________________
Financial concerns:________________________________________
Relationship status:__________________________________________
Cultural factors:___________________________________________
Religion:__________________ Practicing:___________________
Lifestyle:__________________ Recent changes:______________
Feelings of Helplessness:__________ Hopelessness:__________
Powerlessness:___________________________________________
Usual bowel pattern:___________ Laxative use:______________
Character of stool:______________ Last BM:__________________
History of bleeding:_____________ Hemorrhoids:_____________
Constipation:__________________ Diarrhea:_________________
Usual voiding pattern:_____ Incontinence:_____ When:_____
Urgency:________ Frequency:________ Retention:________
Character of urine:___________________________________________
Pain/burning/difficulty voiding:___________________________________________
History of kidney/bladder disease:________________________________________
Usual diet (type):_______________ No. meals daily:___________
Last meal/intake:_______________ Dietary pattern:___________
Loss of appetite:_______________ Nausea/vomiting:__________
Heartburn/indigestion:____ Related to:____ Relieved by:_____
Allergy/Food intolerance:__________________________________
Mastication/swallowing problems:___________________________
Dentures: Upper:_______________ Lower:________________
Activities of daily living: Independent:_______________________
Dependence (specify): Mobility:________ Feeding:_________
Hygiene:________ Dressing:________
Toileting:________ Other:__________
Equipment/prosthetic devices required:____________________________________
Assistance provided by:__________________________________
Preferred time of bath:__________ AM _________ PM
Fainting spells/dizziness:____________________________________
Headaches: Location:_____________ Frequency:_____________
Tingling/Numbness/Weakness (location):______________________
Stroke (residual effects):____________________________________
Seizures:________ Aura:________ How controlled:______________
Eyes: Vision loss: R:________________ L:______________
Glaucoma:__________________ Cataract:______________
Ears: Hearing loss: R:_________________ L:______________
Nose: Epistaxis:_________________ Sense of smell:__________
Pain/Comfort
Location:______ Intensity (1—10):_______ Frequency:_______
Quality:_______ Duration:_____________ Radiation:________
Precipitating factors:______________________________________
How relieved:____________________________________________
Dyspnea (related to):______________________________________
Cough/sputum:___________________________________________
History of: Bronchitis:_____________Asthma:________________
Tuberculosis:__________Emphysema:____________
Recurrent pneumonia:___Other:___________________
Exposure to noxious fumes:_______________________
Smoker:_______ Packs/day:_______ Number of years:________
Use of respiratory aids:_____________ Oxygen:______________
Allergies/Sensitivity:__________ Reaction:__________
Previous alteration of immune system:_______ Cause:__________
History of sexually transmitted disease (date/type):_____________
Blood transfusion:______________ When:__________
Reaction (described):____________________________________
History of accidental injuries:___________________________________
Fractures/dislocations:_____________________________________
Arthritis/Unstable joints:____________________________________
Back problems:___________________________________
Changes in moles:___________ Enlarged nodes:______________
Impaired: Vision:___________ Hearing:____________________
Prosthesis:__________________ Ambulatory devices:__________
Expressions of ideation of violence (self/others):_______________
Age at menarche:_____ Length of cycle:______ Duration:______
Last menstrual period:__________ Menopause:________
Vaginal discharge:_______ Bleeding between periods:_________
Practices breast self-exam:______ Last PAP smear:_____________
Method of birth control:__________
Penile discharge:_____________ Prostate disorder:_____________
Vasectomy:__________________ Use of condoms:________
Practices self-exam: Breast:____ Testicles:_____________________
Last proctoscopic exam:_______ Last prostate exam:________
Marital status:__________ Years in relationship:______________
Living with:______________________________________________
Concerns/Stresses:________________________________________
Extended family:____________________________________________
Other support person(s):______________________________________
Role within family structure:______________________________________
Report of problems related to illness/condition:_______________________________
Coping behaviors:____________________________________________
Do others depend on you for assistance? ____________________________________
How are they managing? __________________________________
Frequency of social contacts (other than work):________________
Dominant language (specify):_______________________________
Education level:_____________________________________________
Learning disabilities (specify):_______________________________
Cognitive limitations (specify):_______________________________
Health beliefs/practices:_____________________________________
Special health care practices:________________________________
Familial risk factors (indicate relationship):
Prescribed medications (circle last dose):
Nonprescription drugs: OTC:_______________________________
Use of alcohol (amount/frequency):_______________________________
Admitting diagnosis (physician):_______________________________
Reason for hospitalization (patient):_______________________________
History of current complaint:_______________________________
Patient expectations of this hospitalization:_______________________________
Previous illness and/or hospitalizations/surgeries:________________
________________________________________________________________
Evidence of failure to improve:_______________________________
Last complete physical exam:_____________ By:_____________
Discharge Plan Considerations
Date data obtained:_______________________________________
* Adapted from Doenges, ME, Moorhouse, MF, and Geissler-Murr, AC: Nursing Care Plans, Guidelines for Individualizing Patient Care, ed 6. FA Davis, Philadelphia, 2002, with permission.