Comprehensive Health Assessment Form
Health History (5 pts total)
Biographical data: (1 pts)
No name or initial required
Age: ________ Marital status: ____M _____ S _____Sep. ____Cohab.
Birth date: _____________________ Number of dependents: ___________________
Educational level: ________________________ Gender: _____F _____ M _____Other
Occupation (current or, if retired, past): ______________________________________
Source of history (who gave you the information and how reliable is that person): _______________________________________________________________________
Present health history: (4 pts)
Current medical conditions/chronic illnesses:
Past health history: (10 pts total)
Childhood illnesses: Ask about history of mumps, chickenpox, rubella, ear infections, throat infections, pertussis, and asthma.
Hospitalizations/Surgeries: Include reason for hospitalization, year, and surgical procedures.
Accidents/injuries: Include head injuries with loss of consciousness, fractures, motor vehicle accidents, burns, and severe lacerations.
Major diseases or illnesses: Include heart problems, cancer, seizures, and any significant adult illnesses.
Immunizations (dates if known):
Tetanus _______ Diphtheria ________ Pertussis ________ Mumps ________
Rubella _______ Polio _____________ Hepatitis B ______ Influenza _______
Varicella ______ Other ____________________________________________
Recent travel/military services: Include travel within past year and recent and past military service.
Date of last examinations:
Physical examination _________ Vision ___________ Dental ___________
Family History (Genogram) (10 points)
Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any major health issues, and, if indicated, cause and age at death Present as a genogram.
Review of Systems (12 points total) Be sure to ask about symptoms specifically.
General health status (1 pt): Ask about fatigue, pain, unexplained fever, night sweats, weakness, problems sleeping, and unexplained changes in weight.
Integumentary (1 pt):
Skin: Ask about change in skin color/texture, excessive bruising, itching, skin lesions, sores that do not heal, change in mole. Do you use sun screen? How much sun exposure do you experience?
Hair: Ask about changes in hair texture and recent hair loss.
Nails: Ask about changes in nail color and texture, splitting, and cracking.
HEENT (2 pts):
Head: Ask about headaches, recent head trauma, injury or surgery, history of concussion, dizziness, and loss of consciousness.
Neck: Ask about neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the neck.
Eyes: Ask about change in vision, eye injury, itching, excessive tearing, discharge, pain, floaters, halos around lights, flashing lights,
Family Genogram Template
Dead, age 86, MI, COPD
Dead, age 35, childbirth
Dead, age 72, stomach cancer
Dead, age 80, cancer, unknown type
Dead, age 92, old age
Dead, age 62, breast cancer
Dead, age 62, drowning
Born 1950 , asthma, endometrial cancer
Dead, age 64, lung cancer
Dead, age 55, breast cancer
Born 1974, breast cancer, asthma
Born 1996 asthma
Great Grand Parents
Dead, no info known
Dead, age38, car accident
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