NURS 6512: Comprehensive Health History Reference Sheet

NURS 6512:

Comprehensive Health History Reference Sheet

⚠

Reminder: The health history includes **subjective data only**

—

information
provided by the patient about their symptoms, perceptions, and experiences.
Objective findings belong in the physical exam section.

Chief Complaint (CC)
• State the patient’s main reason for visit

—

concise and focused.
• Use the patient’s own words in quotes (1
–
2 words or one short sentence).
• Example: “Sore throat for two days.” or “Shortness of breath.”
History of Present Illness (HPI)

–

OLDCARTS + Pertinent History
• Use OLDCARTS to gather data, then synthesize into a cohesive paragraph written
in complete sentences.
• Avoid bullet points. Tell the story of the symptom(s) using the data you collected.
• O

–

Onset: When did it start?
• L

–

Location: Where is it? Does it radiate?
• D

–

Duration: Constant or intermittent?
• C

–

Character: Describe the quality (sharp, dull, throbbing).
• A

–

Aggravating factors: What makes it worse?
• R

–

Relieving factors: What makes it better?
• T

–

Timing: Pattern, frequency, time of day.
• S

–

Severity: 0
–
10 pain scale or functional impact.
• Include associated symptoms and pertinent negatives (important symptoms the
patient denies).
• Incorporate pertinent history such as recent illness, exposures, travel, medications
tried, previous episodes, or related chronic conditions.
• Example: The HPI should read as a full paragraph that flows logically and reflects
critical thinking

—

not as a list of OLDCARTS items.
Past Medical History (PMH)
• Chronic illnesses (HTN, DM, asthma, etc.)
• Childhood illnesses (if relevant)
• Hospitalizations and psychiatric history
Surgical History (PSH)
• List all surgeries/procedures with year, indication, and complications
Medications
• List all: prescription, OTC, herbal, and supplements
• Include name, dose, route, frequency, indication
• Note adherence and side effects

Allergies
• Drug, food, environmental

—

include reaction type (rash, anaphylaxis, etc.)
• Document tolerated alternatives if known
Preventive Health
• Immunizations: Flu, COVID
–
19, Tdap, shingles, pneumococcal
• Screenings: Pap, mammogram, colonoscopy, lipid, glucose, DEXA
• Risk factors: Diet, exercise, safety, sexual health, sleep, stress, dental, vision
Social History
• Tobacco: Type, amount, duration, quit attempts
• Alcohol: Type, frequency, quantity (CAGE if indicated)
• Substance use: Illicit or prescription misuse
• Occupation: Exposures, stress, satisfaction
• Living situation & support system
• Safety: IPV, firearms, seatbelt use
• Social Determinants of Health (SDOH): Housing, food, transport, access, finances
Review of Systems (ROS)
These are

subjective

symptoms that the patient report
s. No objective exam findings
should be included here.
• General: Fever, chills, weight change, fatigue
• Skin: Rashes, lesions, itching
• HEENT: Vision, hearing, congestion, sore throat
• Cardiac: Chest pain, palpitations, edema
• Respiratory: Cough, SOB, wheezing
• GI: N/V/D, constipation, pain, appetite
• GU: Dysuria, frequency, hematuria
• MSK: Joint pain, stiffness, weakness
• Neuro: Headache, dizziness, numbness, seizures
• Psych: Mood, anxiety, sleep
• Endo: Heat/cold intolerance, polyuria/polydipsia
• Heme: Easy bruising/bleeding

NURS 6512: Comprehensive Health History Reference Sheet