SHADOW HEALTH HEALTH HISTORY - WEEK 2 - TINA JONES 2025-
2026- GRADED A+ ✓✓✓ACE YOUR EXAMS-TOP SCORE
HEALTH HISTORY - TINA JONES
ACTIVITY DESCRIPTION VIDEO
The purpose of obtaining a health history is to gather subjective data from the patient and/or
their care partners to collaboratively create a nursing care plan that will promote health and
maximize functioning.
GREETING
Hi Ms. Jones. My name is [your name] and i will be your nurse for today.
HPI (History of Present Illness)
START W/ OPEN-ENDED QUESTIONS
What brings you to the hospital today?
(Allow the patient to answer)
EMPATHIZE - MAKE AN EMPATHETIC STATEMENT
(Helps to build rapport and trust with the patient.)
I'm sorry your're in so much pain. I'm glad you're here so we can help you.
QUALIFY SYMPTOMS - GET MORE INFORMATION ON CONDITION (I.E., INJURY)
Use O-L-D C-A-R-T-S acronym as a reminder of what to ask.
O - Onset
l - Location
D - Duration
C - Characteristics
A - Aggravating Factors
R - Relieving Factors
T - Treatment
S - Severity
PAIN LEVEL
Can you rate your pain on a scale of 1 to 10?
ONSET
When did the pain start?
,BRIEFLY EMPATHIZE AGAIN
I'm sorry you're in so much pain. I will get you pain medication as soon as possible.
LOCATION
Where is your wound?
CONVERSATION HELP
Use correct spelling and grammar.
Try not to use pronouns (e.g., he, she, they, it).
Avoid medical jargon.
Provide clear context for your questions.
Avoid sentence fragments (e.g. "last pap?")
Ask about one subject at a time.
Use the Educate and Empathize tabs.
If you don't get an answer, try asking a more broad question.
PAST MEDICAL HISTORY
Preexisting medical condition
Prior hospitalizations
Medications
Allergies
Immunizations
PREEXISTING MEDICAL CONDITIONS
Do you have any other medical conditions?
MORE INFO ON PRE-EXISTING CONDITION(S)
When were you diagnosed with diabetes?
How are you managing your diabetes?
Do you take any diabetes medication?
Why did you stop taking your diabetes medication?
Are you monitoring your blood glucose?
EDUCATE - DIABETES MANAGEMENT
, Educate on the proper management of diabetes.
Diabetes medication helps your body release or use insulin better, which keeps your body from
making too much sugar. It also helps prevent or delay long-term, serious health problems, such
as heart disease, vision loss, and kidney disease.
Make and eat healthy food, stay active most days, and test your blood sugar often.
Take medicines as prescribed, even if you feel good, and go to your doctor's appointments.
ASK ABOUT SYMPTOMS
Thirsty?
Do you get thirsty often?
How much water do you drink in a day?
Urinary Frequency?
How often do you urinate? (void)
Weight changes?
Have there been any weight changes since stopping your diabetes medication?
Diet?
What do you normally eat in a day?
How many meals do you eat in a day?
Do you drink any sugary drinks, soda, or juices?
ANOTHER PREEXISTING CONDITION - ASTHMA
Ask questions to get a full understanding of asthma and its management.
How often do you have asthma attacks?
Do you know what triggers the asthma attacks?
What asthma symptoms have you experienced?
What usually works to treat an asthma attack?
How often do you use your asthma inhaler?
How many puffs do you take when using your inhaler?
IMMUNIZATIONS
Have you had all of your childhood immunizations?
FLU VACCINATION
2026- GRADED A+ ✓✓✓ACE YOUR EXAMS-TOP SCORE
HEALTH HISTORY - TINA JONES
ACTIVITY DESCRIPTION VIDEO
The purpose of obtaining a health history is to gather subjective data from the patient and/or
their care partners to collaboratively create a nursing care plan that will promote health and
maximize functioning.
GREETING
Hi Ms. Jones. My name is [your name] and i will be your nurse for today.
HPI (History of Present Illness)
START W/ OPEN-ENDED QUESTIONS
What brings you to the hospital today?
(Allow the patient to answer)
EMPATHIZE - MAKE AN EMPATHETIC STATEMENT
(Helps to build rapport and trust with the patient.)
I'm sorry your're in so much pain. I'm glad you're here so we can help you.
QUALIFY SYMPTOMS - GET MORE INFORMATION ON CONDITION (I.E., INJURY)
Use O-L-D C-A-R-T-S acronym as a reminder of what to ask.
O - Onset
l - Location
D - Duration
C - Characteristics
A - Aggravating Factors
R - Relieving Factors
T - Treatment
S - Severity
PAIN LEVEL
Can you rate your pain on a scale of 1 to 10?
ONSET
When did the pain start?
,BRIEFLY EMPATHIZE AGAIN
I'm sorry you're in so much pain. I will get you pain medication as soon as possible.
LOCATION
Where is your wound?
CONVERSATION HELP
Use correct spelling and grammar.
Try not to use pronouns (e.g., he, she, they, it).
Avoid medical jargon.
Provide clear context for your questions.
Avoid sentence fragments (e.g. "last pap?")
Ask about one subject at a time.
Use the Educate and Empathize tabs.
If you don't get an answer, try asking a more broad question.
PAST MEDICAL HISTORY
Preexisting medical condition
Prior hospitalizations
Medications
Allergies
Immunizations
PREEXISTING MEDICAL CONDITIONS
Do you have any other medical conditions?
MORE INFO ON PRE-EXISTING CONDITION(S)
When were you diagnosed with diabetes?
How are you managing your diabetes?
Do you take any diabetes medication?
Why did you stop taking your diabetes medication?
Are you monitoring your blood glucose?
EDUCATE - DIABETES MANAGEMENT
, Educate on the proper management of diabetes.
Diabetes medication helps your body release or use insulin better, which keeps your body from
making too much sugar. It also helps prevent or delay long-term, serious health problems, such
as heart disease, vision loss, and kidney disease.
Make and eat healthy food, stay active most days, and test your blood sugar often.
Take medicines as prescribed, even if you feel good, and go to your doctor's appointments.
ASK ABOUT SYMPTOMS
Thirsty?
Do you get thirsty often?
How much water do you drink in a day?
Urinary Frequency?
How often do you urinate? (void)
Weight changes?
Have there been any weight changes since stopping your diabetes medication?
Diet?
What do you normally eat in a day?
How many meals do you eat in a day?
Do you drink any sugary drinks, soda, or juices?
ANOTHER PREEXISTING CONDITION - ASTHMA
Ask questions to get a full understanding of asthma and its management.
How often do you have asthma attacks?
Do you know what triggers the asthma attacks?
What asthma symptoms have you experienced?
What usually works to treat an asthma attack?
How often do you use your asthma inhaler?
How many puffs do you take when using your inhaler?
IMMUNIZATIONS
Have you had all of your childhood immunizations?
FLU VACCINATION
