St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue, 2727 Bantay, Ilocos Sur

NCM 101: Health Assessment

Module 3

COMPREHENSIVE HEALTH HISTORY

Melanio P. Rojas Jr, MAN

Clinical Instructor

2024

Module No. 3
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 COMPREHENSIVE HEALTH HISTORY

Learning Objectives:

After completing this module, the students will be able to:

1. Explain the comprehensive health history.

2. Discuss explain the general overall health state.

3. Performing general health assessment

COMPREHENSIVE HEALTH HISTORY

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The purpose of health history is to collect subjective data- what the patient says about himself or
herself. The history is combined with objective data from the physical examination and
laboratory studies to form the data base.
The health history provides a comprehensive portrait of the patient’s past and present health.
The components of a health history are as follows:
1. Biographic
2. Reason for seeking care (Chief complaint)
3. Presence health or history of present illness
4. Current medications
5. Family history
6. Review of systems
7. Functional assessment of activities of daily living (ADL’s)
The Health History- The Adult
1. Biographic Data
 Name
 Address and phone number
 Age and birth date
 Gender
 Marital Status
 Race, Ethnic Origin
 Occupation (usual and present – an illness or disability may have prompted change
in occupation)
 Language and communication needs (primary language and authorized
representative should be recorded; if the patient does not speak English or
Filipino/Tagalog, specify the language/dialect spoken (e.g. speak Iloko only, speaks
Korean only.
Source of History
1. Record who furnishes the information (e.g., the patient, relative, friend)
2. Judge how reliable the information seems and how willing he or she to
communicate.
3. Noted any special circumstances, such as the use of interpreter.

2. Reasons for Seeking Care (Chief Complaint)

 This is brief spontaneous statement in the patient’s own words that describes
the reason for the visit.
 A sign is an objective abnormality that can be detected on physical examination
or in laboratory studies.
 A symptom is a subjective that the person feels from the disorder.
 The chief complaint is enclosed in quotation marks to indicate the person’s exact
words. This is now replaced with “reason for seeking care” that incorporates
wellness needs.

Examples:
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 “Chest pain for 2 hours.”
“Earache and fussy all night.”
“Dizziness and ringing of the right ear.”
 The chief complaint is not diagnostic statement. Avoid translating it into terms of
a medical diagnosis (e.g., “increasing shortness of breath for fours,” not
emphysema.”

3. Present Health or History of Present Illness

 For the well person, this is a short statement about general state of health.
 For the ill person, this is a chronological record of the reason for seeking care,
from the time the symptom first started until now. Example: “Please tell me all
about your headache, from the time it started until the time you came to the
hospital.”
 The final summary of any symptom should include the following eight critical
characteristics:
a. Location
E.g., pain- “pain behind the eyes,” “jaw pain.” Is the pain localized to this site,
or radiating?” “Is the pain superficial or deep?”
b. Quality or Character. This calls for specific descriptive terms such as
burning, sharp, dull, aching, gnawing, throbbing, shooting, viselike. Uses
similes- “Does blood in the stool look like sticky tar?” “Does blood in the
vomitus look like coffee-grounds?”
c. Quantity or Severity. Attempt to quantify the sign and symptom, e.g.,
“profuse menstrual flow soaking five pads per hour.”
d. Timing (Onset, Duration, Frequency)
 When did the symptoms first appear? Or state specifically how long
ago the symptoms started prior to arrival.
 How long did the symptom last?
 Was it steady? (constant) or did it come and go during that time
(intermittent)
e. Setting. Where the person or what was the person doing when the symptom
started? What brings it on?
Example: “Did you notice the chest pain after carrying a heavy load, or did
the pain start by itself?
f. Aggravating or Relieving factors
 What makes the pain worse?
Example: “It is aggravated by weather, activity, food, medication, time
of the day, season and so on?
 What relieves it (e.g., rest, medication, ice pack)?
 What is the effect of treatment?
Example: “What have you tried?” or “What seems to help?”
g. Associated Factors. Are the primary symptoms associated with any others
(e.g., urinary frequency and burning associated with fever and chills?)
Review the body system related to this symptom now rather than wait for the
review systems.
h. Patient’s perception. Find out the meaning of the symptom by asking how it
affects daily activities.
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To help remember all the points, organize this question sequence into the mnemonic PQRSTU.
P: Provocative or Palliative. What brings it on? What were you doing when you first notice?
What makes it better? Worse?
Q: Quality or Quantity. How does it look, feel, sound? How intense/severe is it?
R: Region or Radiation. Where is it? Does it spread anywhere?
S: Severity Scale. How bad is it? (on a scale of 1 to 10?) Is it getting better, worse, staying
the same?
T: Timing. Onset- exactly when did it first occur? Duration- how long did it last? Frequency-
how often does it occur?
U: Understand Patient’s Perception of the Problem? What do you think it means?
4. Past Health History
 Past health events may have residual effects on the current state of health.
 Previous experience with illness may give clues on how the patient responds to
illness and to the significance of illness for him or her.
a. Childhood Illness. Measles, mumps, rubella, chicken pox, pertussis and strep
throat
b. Accidents or injuries. Auto accidents, fractures, head injuries, burns, falls
c. Serious or Chronic Illnesses. Diabetes, hypertension, heart disease, cancer,
seizure disorder
d. Hospitalizations. Cause, name of hospital, how the condition was treated, how
long the person was hospitalized and name of the physician.
e. Operations. Types of surgery, date, name of the surgeon, name of hospital and
how the person recovered.
f. Obstetric History: Number of pregnancies (Gravity) number of deliveries in
which the fetus reached full term, number of preterm pregnancies, number of
abortions and number of children living. This is recorded: Gravida__________
Term__________ Preterm__________ Abortion__________Living________
g. Immunizations: Meales-Mumps-Rubella (MMR), polio, diphtheria-pertussis-
tetanus (DPT), hepatitis B, human papilloma virus (HPV), haemophilus
influenza type b ( Hib), pneumococcal. Note the date of the last tetanus
immunization, last tuberculosis skin test and last flu shot.
h. Last Examination Date: Physical, dental, vision, hearing, electrocardiogram
(ECG), chest X-ray examination
i. Allergies: Note both allergies (medication, food, or contact agent) and the
reaction (rash, itching, runny nose, watery eyes, and difficulty of breathing).
5. Current Medications (Medication Reconciliation)
 Note all prescription and over-the-counter (OTC) medications and herbal
remedies.
 Ask specifically for vitamins, birth control pills, aspirin and antacids
 For each medication, note the name, dose and schedule and ask. “How often do
you take it each day?” “What is it for?” and “How long have you been taking it?”

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  Prescribed medications may have adverse interactions with OTC’s and herbal
medications.
 This also ensures evaluation of medications taken by the patient by the
physician- either to continue the medication unchanged, to continue but change
the dose, or to discontinue the medication.
6. Family history
 Ask about the age and health or age and cause of death of blood related such as
parents, grandparents and siblings. These data may have genetic significance for
the patient.
 Ask family history of heart disease, high blood pressure, stroke, diabetes, blood
disorders, cancer, anemia, arthritis, allergies, obesity, alcoholism, mental illness,
seizure disorder, kidney disease and tuberculosis.
7. Review of System (ROS)
 The order of the examination is from head to toe.
 Remember, that the health history should be limited to patient statements or
subjective data-factors that the person says were not present.
GENERAL OVERALL HEALTH STATE
Skin

 History of skin (eczema, psoriasis), change in pigmentation, texture, or color, change in

mole, excessive dryness, sweating pruritus, hair growth and distribution, excessive
bruising.
Hair

 Recent loss, change in texture. Nails: change in shape, color or brittleness.

 Health promotion: amount of sun exposure, method of self-care for skin and care.
Head

 Any unusually frequent or severe headache, any head injury, dizziness, vertigo,
syncope.
Eyes

 Difficulty with vision (decreased activity, blurring, blind spots), eye pain, diplopia (double
vision), redness or swelling, watering or discharge, glaucoma, cataracts, photophobia,
itching.
 Health promotion: Wear glasses or contacts; last vision check or glaucoma test; and how
is he/she coping with loss of vision of any.
Ears

 Earaches, infections, discharge and its characteristics, tinnitus (ringing of the ears) or
vertigo (sensation of the spinning of the room or self).
 Health promotion: Hearing loss, hearing aid use, how loss affects daily life, any exposure
to environmental noise and methods of cleaning ears.
Nose and Sinuses

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  Discharge and characteristics, any unusually frequent or severe colds, sinus pain, nasal
obstructions, nosebleeds, allergies, or hay fever, or change in the sense of smell.
Mouth and Throat

 Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth and tongue,
dysphagia (difficulty in swallowing), hoarseness or voice change, tonsillectomy, altered
taste.
 Health promotion: pattern of daily dental care, use of prostheses (dentures, bridge) and
last dental check-up.
Neck

 Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter,

Breast

 Pain, lump, nipple discharge, history of breast disease, any surgery on the breasts.
 Health promotion: Performs breast self-examination, including its frequency and method
used, last mammogram.
Axila

 Tenderness, lump or swelling, rash

Respiratory System

 History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis).

 Chest pain with breathing
 Wheezing or noisy breathing
 Shortness of breath. How much activity produces shortness of breath?
 Cough, sputum (color, amount), hemoptysis (coughing up with blood).
 Toxin or pollution exposure
 Health promotion: Last chest x-ray study
Cardiovascular System

 Precordial or retrosternal pain

 Palpitations
 Cyanosis (bluish discoloration of the skin)
 Dyspnea (shortness of breath)
 Orthopnea (difficulty in breathing when lying down, relieved by upward position)
 Paroxysmal nocturnal dyspnea (difficulty in breathing 2 to 5 hours after going to sleep
during the night).
 Nocturia (frequent urination during the night)
 Edema
 History of murmur
 Hypertension, coronary artery disease, anemia
 Health promotion: Date of last ECG or other heart tests
Peripheral Nervous System
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  Coldness, numbness and tingling, swelling of legs (time of day, activity)
 Discoloration in hands or feet (bluish red, pallor, mottling, association with position,
especially around feet and ankles)
 Varicose veins or complications
 Intermittent claudication (leg pain on activity and exercise relieved by rest)
 Thrombophlebitis, ulcers
 Health promotion: Does the work involve long-term sitting or standing? Avoid crossing
the legs at the knees. Wear support hose.
Gastrointestinal System

 Appetite, food intolerance

 Dysphagia (difficulty in swallowing, heart burn, indigestion, pain associated with eating)
 Abdominal pain, pyrosis (esophageal and stomach burning sensation with sour
eructation)
 Nausea and vomiting, hematemesis (vomiting blood)
 History of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis)
 Flatulence, frequency of bowel movement, stool characteristics, constipation, or
diarrhea, black stools
 Rectal bleeding, rectal conditions (hemorrhoids, fistula)
 Health promotion: use of antacids or laxatives
Urinary System

 Frequency, urgency, nocturia

 Dysuria, polyuria, oliguria
 Hesitancy or straining, narrowed stream
 Urine color (cloudy or presence of hematuria)
 Incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract
infections, prostate enlargement)
 Pain in flank, groin, suprapubic region or low back
 Health promotion: measures to avoid or treat urinary tract infections, use of Kegel’s
exercises after birth
Male Genital System

 Penis or testicular pain

 Sores or lesions, penile discharge, lumps, hernia
 Health promotion: Perform testicular self- examination? How frequently?
Female Genital System

 Menstrual history (age at menarche, last menstrual period, cycle duration, any
amenorrhea, menorrhagia, premenstrual, pain or dysmenorrheal, intermenstrual
spotting).
 Vaginal itching, discharge and its characteristics.
 Age at menopause, menopausal signs and symptoms, postmenopausal bleeding.
 Health promotion: Last gynecologic check-up and last Papanicolaou test.

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Musculoskeletal System

 History of arthritis or gout

 In the joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation of
motion, crepitus (noise with joint motion)
 In the muscles, any pain, cramps, weakness, gait problems, problems with coordinated
activities.
 In the back: any pain (location and radiation to extremities), stiffness, limitation of
motion, history of back pain or disk disease.
 Health promotion: How much walking per day? What is the effect of limited range of
motion on daily activities such as grooming, feeding, toileting, and dressing?
Neurologic System

 History of seizure disorder, stroke, fainting blackouts.

 In motor function: weakness tic or tremor, paralysis or coordination problems.
 In sensory function: numbness and tingling (paresthesia).
 In cognitive function: memory disorder (recent, distant), disorientation.
 In mental status: any nervousness, mood change, depression or a history of mental
health dysfunction or hallucinations.
 Health promotion: Interpersonal relationships and coping patterns.
Hematologic System

 Bleeding tendency of skin or mucous membranes, excessive bruising

 Lymph node swelling
 Exposure to toxic agents or radiation
 Blood transfusion and reactions
Endocrine System

 History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia)

 History of thyroid disease, intolerance to heat and cold, change in skin pigmentation or
texture, excessive sweating, relationship between appetite and weight, abnormal hair
distribution, nervousness, tremors, need for hormone therapy.

8. Functional Assessment (including Activities of Daily Living)

 Functional assessment measures a person’s self-care ability in the areas of
general physical health or absence of illness. This includes the following:
1. Activities of Daily Living (ADL’s)
e.g., bathing, dressing, toileting, eating, walking.
2. Instrumental Activities of Daily Living or those needed for independent living.
3. Nutrition
4. Social relationship and resources
5. Self-concept and coping
6. Home environment

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  Functional Assessment questions which should be included in the standard
health history are as follows:
1. Self-esteem, Self-concept
Educational attainment and trainings
Financial status (income)
Religious practices and perception of personal strengths (value belief system)
2. Activity/Exercise
Usual daily activities (ask: “Tell me how you spend a typical day?”)
Ability to perform ADL’s: independent or needs assistance with feeding, bathing,
hygiene, dressing, toileting, bed to chair, transfer, walking, standing, or climbing
stairs.
Any use of wheelchair, prostheses or mobility aids?
Leisure activities enjoyed
Exercise pattern (type, amount per day or week, method of monitoring the body’s
response to exercise).
3. Sleep and Rest
Sleep patterns
Daytime naps
Any sleep aids (sleeping pills, CPAP for sleep apnea/snoring)
4. Nutrition/Elimination
Diet recall (24-hour recall)
Eating habits and current appetite
Asks: “Who buys food and prepares food?”
“Are your finances adequate for food?”
“Who is present at mealtimes?”
5. Interpersonal Relationship/Resources
Social Roles: “How would you describe your role in the family?”
Support System: “To whom could you go for support with a problem at work, with
your health, or a personal problem?”
6. Spiritual Resources:
Faith: “Do you consider yourself to be a religious or spiritual person?”
Influence: “Do you consider yourself to be a religious or spiritual person?”
Community: “Are you part of any religious or spiritual community?”
Address: “Would you like me to address any religious or spiritual issues or concerns
with you?”
7. Coping and Stress Management
Methods tried to relieve stress, and if these have been helpful.
8. Personal Habits
Tobacco, Alcohol
 Tobacco Use
“Do you smoke cigarettes?”
“At what age did you start?”
 Alcohol
“Do you drink alcohol?”
“When was your last drink?”

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 9. Environment/Hazards
Housing and neighborhood
 Safety of area
 Adequate ventilation and utilities
 Access to transportation
 Involvement in community services
10. Intimate Pattern: Violence
Begin with open-ended questions.
Ask: “How are things at home?”
“Do you feel safe?”
11. Occupational Health
Ask the patient to describe his or her job.
“Ever worked with any health hazard such as inhalants, chemicals?”
“Wear any protective equipment?”
12. Perception of Health
Ask: “How do you define health?”
“What are your concerns?”
“What are your health goals?”
DEVELOPMENTAL CARE
A. Additional Information for Health history for pediatric patients.
13. Reason for Seeking Care
 Record the parent’s spontaneous statement. Reasons given by parents may be,
“time for the child’s check-up,” she needs the next vaccine/immunization.”
 A parent may have a “hidden agenda” such as a mother bringing 4-year old child
to the clinic because the child “looked pale.” Further questioning revealed that the
motor had heard recently from a friend whose own 4-year old child had just been
diagnosed with leukemia.
14. Present Health or History of Present Illness
 Include a statement about the usual health of the child and any common health
problems or major health problems.
 Examples:
 The child’s health status is generally good as stated by mother.
 The child is in pain, as claimed by the mother.
 The child had “one asthmatic attack” for the past 3 months.
 Describe any presenting sign or symptom. Use the same format as for the adult.
Some additional considerations include:
 Severity of Pain
 “How do you know; the child is in pain?”
 Effect of pain on usual behavior
 “Refuses feeding.”
 “Stops him/her from playing.”
 “Refuses to go to school.”
 “Stays in bed most of the time.”
 Parent’s coping ability and reaction of other family member’s child’s symptoms
or illness.

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15. Past Health
 Prenatal Status
 How was this pregnancy speed?
 Was it planned?
 What was the mother’s health during pregnancy?
 Where there any complications (e.g., bleeding, excessive nausea and
vomiting, unusual weight gain, high blood pressure, swelling of hands and
feet, infections- German measles/rubella, sexually transmitted infection)?
 What diet and medications were prescribed and/or taken during
pregnancy?
 Did the mother undergo any x-ray studies during pregnancy?
 Labor and Delivery
 Parity of the mother (e.g., Gravida, Para)
 Duration of pregnancy (e.g., 9 months)
 Place of delivery ( e,g., normal/vaginal delivery, cesarean section, vertex
( head is presenting part) and breech ( buttocks is presenting part)
 Birth weight, birth length, head circumference, chest circumference,
APGAR score, onset of breathing, any cyanosis, need for resuscitation
and use of special equipment or procedure.
 Postnatal Status
 Any problems in the nursery?
 Length of hospital stay
 Neonatal jaundice (e.g., after 24 hours, first 24 hours of birth)
 Whether the baby was discharged with the mother, needed stay longer in
the nursery.
 Any feeding problems, “ blue-spells”, “colic diarrhea”
 Patterns of crying and sleeping
 Mother’s health postpartum
 Mother’s reaction to the baby
 Childhood illnesses
 Age when any of the following illnesses was/were experiencing measles,
mumps, rubella, chickenpox, whooping cough, sore throat, ear infections.
 Serious accidents or injuries
 Age of occurrence
 Extent of injury
 How the child was treated
 Complications of auto accidents, falls, head injuries, fractures, burns and
poisonings.
 Serious or Chronic Illnesses
 Age of onset
 How the child was treated?
 What are the complications?
 Examples: meningitis, encephalitis, seizure disorder, asthma, pneumonia,
rheumatic fever, diabetes, kidney problems, tuberculosis, otitis media and
allergies.

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  Operations or hospitalizations
 Reason for care
 Age of admission
 Name of physician and hospital
 Duration of stay
 How the child reacted to hospitalization
 Any complications
 Immunizations
 Age when administered
 Date administered
 Any reactions following immunizations
 Allergies
 Any foods, drugs, contact agents, environmental agents to which the child
is allergic, reaction to allergen.
 Examples of allergens
 Eggs, peanut butter, snack foods, shrimps
 Aspirin, acetaminophen, penicillin
 Dust, pollen, grass, molds, roaches, animal danders
 Extremes of temperature (cold or warm weathers)
 Medications
 Any prescription and over-the-counter medications (or vitamins) the child
takes, including the dose, daily schedule, why the medication is given and
any problems.
DEVELOPMENTAL HISTORY
 Growth
 Height and weight at birth and at 1, 2, 5 and 10 years.
 Process of dentition
 Milestones
 Motor development (e.g., age when child first held head erect, rolled over,
sat up, walked alone, tied shoes, dressed without help)
 Language (e.g. age when child first said “mama” and “dada”
 Toilet training (e.g. age when the child achieved bowel bladder control)
 Do the parents believe this development has been normal?
 How does this child’s development compare with siblings and peers?
 Current Development
 Gross motor skills (rolls over, sits alone, walks alone, skips and climbs)
 Fine motor skills (bring hands to mouth, pincer graps, blocks, feed self,
uses crayons to draw, uses scissors)
 Language skills (first words with meaning, vocabulary, sentences
persistence of baby talk)
 Personal-social skills (smiles, follows movement with eyes, turn head
towards sounds, recognizes own name)
 Toilet-training (method used, age of bowel/bladder control parents’
attitude towards toilet-training terms used for toileting).

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  Nutritional History
 Breast feeding or bottle-feeding (for infants)
 Frequency, amount, duration, supplements and method of weaning
 Any problems with bottle-feeding (spitting up, colic and diarrhea)
 Introduction of solid foods- what foods are given, child’s reaction to new
food.
 For preschool, school-age children and adolescents
 Appetite to eat
 24-hour diet recall
 Vitamins taken
 How much junk food is eaten?
 Foods likes and dislikes
 Parent’s perception of child’s nutrition
 Family History
 As the adult, ask for family history of heart disease, high blood
pressure, diabetes, blood disorders, cancer, arthritis, allergies, obesity,
tuberculosis, mental illness, seizure disorder, kidney disease,
alcoholism, mental retardation, learning disabilities and birth defects.

B. Additional Information for Health History in Pregnancy

16. Age
 Adolescent (younger than 19 years old) have an increased incidence of anemia,
pregnancy-induced hypertension/PIH, preterm labor/PTL, small –for-gestational,
infants, intrauterine growth retardation, cephalo-pelvic disproportion and dystocia
(prolonged, difficult, painful labor).
 Women of advanced maternal age (over 35 years of age) have increased
incidence of hypertension, pregnancies complicated underlying medical
problems such as diabetes, medical gestation and infants with genetic
abnormalities.
17. Family History
 Maternal and Paternal History
 Congenital disorders, hereditary diseases, multiple pregnancies, diabetes, heart
disease, hypertension, mental retardation, renal disease or use of
diethylstilbestrol.

18. Woman’s Medical History

 Childhood diseases (e.g., rubella measles, chicken pox)
 Major illness surgery
 Drug, food, environmental allergens
 Urinary infections, heart disease, diabetes, hypertension, endocrine disorders
and anemias.
 Use of oral or other contraceptives
 History of sexually transmitted diseases
 Menstrual history- start of menarche, duration, amount, regularity and pain
(dysmenorrhea) and bleeding between periods (metrorrhagia).

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  Use of medications, prescription, over-the-counter OTCs other drugs, alcohol,
tobacco and caffeine.
 History of TB, hepatitis B, group B beta streptococcus, or human
immunodeficiency virus.
19. Woman’s Past Obstetric History
 Problems of infertility, dates of previous pregnancies and deliveries infant,
weights; length of labor, types of deliveries, multiple abortions, maternal, fetal
and neonatal complications.
 Woman’s perception of past pregnancy, labor and delivery for herself and
effect on her family.
20. Woman’s Present Obstetric History
 Gravidity, Parity
 Gravida (G) - woman who is or has been pregnant, regardless
pregnancy outcome.
 Para (P) - refers to the past pregnancies that has reached viability.
 Nulligravida- woman who is not now and never has been pregnant.
 Primigravida- woman pregnant for the first time.
 Nullipara- woman who has never completed a pregnancy to the period
of viability (capability of living, 24 weeks).
 Primipara- woman who has completed one pregnancy to the period of
viability regardless of the number of infants delivered and regardless of
the infant being live or stillborn.
 Multipara- woman who has completed two or more pregnancies to the
stage of viability.
 Examples:
G1P0- a woman pregnant for the first time (primigravida).
G2P1- a woman who is pregnant for the second time and has delivered
one fetus carried to the period of viability.
 Obstetrics history may be summarized by a series of 4 digits using
abbreviation TPAL or by a series of 6 digits using the abbreviation
GTPALM.
T- Term/full term deliveries; above 37 weeks completed or more.
P- Preterm deliveries; 20 to less than 37 weeks completed weeks.
Abortions; elective or spontaneous loss of pregnancy before the period
of viability (less than 20 weeks).
L- Living children a woman has delivered regardless of whether they
were live births or stillborn births.
M-Multiple gestation and births (not the number of neonates delivered).
 Example: G5, P5-0-0-6-1
The woman has been pregnant 5 times, 5 has term deliveries, 0
preterm, 0-abortion, 6-living children and 1- multiple gestation/birth.
 Date of last menstrual period (LMP)
First day of last menstrual period
Estimated date of birth- expected date of confinement/delivery
 Nagele’s Rule: Expected date of delivery
1. Subtract 3 months
2. Add 7 days to the first day of LMP

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 3. Add 1 year

 Example: LMP is April 9, 1978 (4/9/78)

4 9 78
-3 +7 +1
1 16 79
 Signs and symptoms of pregnancy: amenorrhea (absence of menstruation)
breast changes, nausea and vomiting, urinary frequency, skin pigmentation,
enlargement of the abdomen, fetal movement.
 Rest and sleep patterns- length, quality and regularity of the rest and
sleep.
 Activity and employment- exercise, patterns, type and hours of
employment, exposure to hazardous material, plans for continued
employment.
 Sexual activity- sexual satisfaction, frequency, and positions during
intercourse.
 Diet history- weight gain, eating patterns (times and frequency eating
daily), social or cultural dietary habits, amount and quality of foods taken
daily, history of eating disorders (obesity, anorexia and bulimia).
 Psychosocial status- emotional changes she is experiencing woman’s and
family reaction’s to present pregnancy and support system.

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