Discussion: Building a Health History

NURS 6512 Week 1: Building a Comprehensive Health History

Discussion: Building a Health History

Permalink: https://nursingpaperslayers.com/discussion-build…a-health-history/ ‎

Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment:

For this Discussion, you will play the role of a clinician who is compiling a health history for one of the new patients listed below:

76-year-old Black/African-American male with impairments residing in the city

Adolescent Hispanic/Latino boy from a middle-class suburb 55-year-old Asian woman residing in a high-density poor housing complex a pre-school-aged white female from a remote community 16-year-old white pregnant adolescent living in an inner-city area

Discussion: Building a Health History

To get ready:

Consider the following, keeping in mind the facts offered in Chapter 1:

How would your communication and interview strategies for gathering a health history differ from one patient to the next?

How might you tailor your health history questions based on the patient’s age, gender, ethnicity, or environment?

What risk assessment tools would be suitable to utilize with each patient?

What questions would you ask each patient in order to assess his or her health risks?

Choose one patient from the list above to focus on for this Discussion.

Identify any potential health-related hazards that should be considered depending on the patient’s age, gender, ethnicity, or environmental situation.

Choose one of the risk assessment instruments described in Chapter 1 or Chapter 26 of the course material, or another tool with which you are familiar, and apply it to your chosen patient.

Create at least five specific questions. You’d ask your chosen patient to analyze his or her health risks and start compiling a health history.

Please submit a one-page paper in APA format.

1. a description of the interview and communication methods you would employ with your chosen patient

2. Describe why you might employ these strategies.

3 Identify the risk assessment tool you choose and explain why it is appropriate for the patient you chose.

4 Give at least five specific questions that you would ask the patient.

Discussion: Building a Health History

According to a 2011 Gallup poll, nurses are ranked as the most trusted professionals in the United States. One of the most admired nursing skills is the ability to put patients at ease. When patients enter into a healthcare setting, they are often apprehensive about sharing personal health information. Caring nurses can alleviate the hesitance of patients and encourage them to be forthcoming with this information.

The initial health history interview can be an excellent opportunity to develop supportive relationships between patients and nurses. Nurses may employ a variety of communication skills and interview techniques to foster strong bonds with patients and to effectively facilitate the diagnostic process. In conducting interviews, advanced practice nurses must also take into account a range of patient-specific factors that may impact the questions they ask, how they ask those questions, and their complete assessment of the patient’s health.

This week, you will consider how social determinants of health such as age, gender, ethnicity, and environmental situation impact the health and risk assessment of the patients you serve. You will also consider how social determinants of health influence your interview and communication techniques as you work in partnership with a patient to gather data to build an accurate health history.

Objectives of Learning

The students will:

Examine the communication approaches utilized to gather patients’ health histories in light of social determinants of health.
Examine health-related risks
Apply patient interviewing, diagnostic reasoning, and patient information recording concepts, theories, and principles.

Resources for Learning

Readings Required (click to expand/collapse)

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 1, “The History and Interviewing Process”
This chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.

Chapter 5, “Recording Information”
This chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–29)

Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C. G., … Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: Results of a cohort study. BMC Family Practice, 16, 1–12. https://doi-org.ezp.waldenulibrary.org/10.1186/s12875-015-0241- x

Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal, (1079), 508–513.

Lushniak, B. D. (2015). Surgeon general’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, (1), 3.

Jardim, T. V., Sousa, A. L. L., Povoa, T. I. R., Barroso, W. K. S., Chinem, B., Jardim, L., … Jardim, P. C. B. V. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Public Health, 15(1111), 1–7. https://doi-org.ezp.waldenulibrary.org/10.1186/s12889-015-2477-8

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Shadow Health Nursing Documentation Tutorial (Word document)

Optional Resource

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw- Hill Medical.
Chapter 2, “History Taking and the Medical Record” (pp. 15–33)

Required Media (click to expand/reduce)

Welcome and General Course Guidelines
Dr. Tara Harris reviews the overall guidelines and the expectations for the course. Consider how you will manage your time as you review your media and Learning Resources throughout the course to better prepare for your Discussions, Case Study Lab Assignments, Digital Clinical Experience (DCE) Assignments, and your Midterm and Final Exams (14m).

Module 1 Introduction
Dr. Tara Harris reviews the overall expectations for Module 1. Please pay special attention to the registration requirements for your use of Shadow Health for your Digital Clinical Experience (DCE) Assignments as well as the criteria for the DCE Assignments (3m).

Building a Health History Discussion

An accurate and complete patient history requires effective communication. Many factors influence a patient’s health or sickness, including age, gender, ethnicity, and environmental location. You must be aware of these factors as an advanced practice nurse and modify your communication tactics accordingly. This will not only help you create rapport with your patients, but it will also allow you to obtain the information needed to analyze their health risks more efficiently.

Discussion: Building a Health History

For this Discussion, you will play the role of a physician constructing a health history for a specific new patient assigned by your Instructor.

Photo Credit: Sam Edwards / Caiaimage / Getty Images

To get ready:

Consider the following, keeping in mind the facts offered in Chapter 1 of Ball et al. :

Your Instructor will assign you a fresh patient profile for this Discussion by Day 1 of this week.

Please read the classroom’s “Course Announcements” section for your new patient profile assignment.
How would your communication and interview strategies for gathering a health history differ from one patient to the next?
How may you tailor your queries to the patient’s socioeconomic determinants of health when compiling a health history?
What risk assessment tools should you employ with each patient, and what questions should you ask each patient to assess his or her health risks?
Identify any potential health-related hazards that should be considered depending on the patient’s age, gender, ethnicity, or environmental situation.
Choose one of the risk assessment instruments described in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination manual, or another tool with which you are familiar, and apply it to your chosen patient.
Create at least five targeted questions to ask your chosen patient in order to analyze his or her health risks and begin constructing a health history.
By the third day of Week 1,

Post an interview summary as well as a description of the communication tactics you would employ with your allocated patient. Explain why you would employ these strategies. Describe the risk assessment instrument you choose and explain why it is appropriate for the patient you chose. Give at least five specific questions that you would ask the patient.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Read some of your coworkers’ responses.

By Week 1’s Day 6

Respond to at least two of your coworkers who chose a different patient than you on two different days, using one or more of the following approaches:

Share any additional interview and communication tactics that you think would be useful with your colleague’s chosen patient.
Please suggest any additional health-related dangers that should be examined.
Use your own experience and further research to validate a notion.
Submission and Grading Details
Criteria for Evaluation

To access your rubric:
Week 1 Discussion Rubric

Post by Day 3 of Week 1 and Respond by Day 6 of Week 1

To Participate in this Discussion:
Week 1 Discussion

What’s Coming Up in Module 2?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

In Module 2, you explore the impact of functional assessments, diversity, and sensitivity in conducting health assessments. You also examine various assessment tools and diagnostic tests used to gather information about patients’ conditions and examine their validity, reliability, and impact in conducting health assessments.

Next week, you will specifically examine functional assessments as they relate to diversity and sensitivity

Registration for Shadow Health

Throughout this course, you will participate in digital clinical experiences using the online simulation tool Shadow Health. The Shadow Health digital clinical experience provides a dynamic, immersive experience designed to improve nursing skills and clinical reasoning through the examination of digital standardized patients. Using Shadow Health you will participate in health histories, focused exams, and a comprehensive assessment.

There will be four Shadow Health assessment components that you will need to complete in Module’s 2 and 3:

Health History Assessment (Week 3 & 4)
Focused Exam: Cough (Week 5) for a pediatric patient presenting with cough
Focused Exam: Chest Pain (Week 7) for an adult patient presenting with chest pain
Comprehensive (Head-to-Toe) Physical Assessment (Week 9)

Before you can participate in these simulations, you will need to register for a Shadow Health account. To do this:

Go to the Walden Bookstore and purchase access to Shadow Health and the required texts.
Once Shadow Health has been purchased, an access code will be emailed to you from the bookstore.
Review this video explaining how to register in Shadow Health: https://vimeo.com/275921826/c12d50ee6e
Use the Shadow Health link located in the navigation menu on the left in the Blackboard course.
Follow the prompts to register in Shadow Health. You will need the access code provided from the bookstore to register. Once registered, Shadow Health should always be accessed via the link in Blackboard.
Use only Google Chrome when accessing Shadow Health and make sure all other programs are turned off on your computer. Other browsers do not work well and will not allow the Shadow Health speech to text function to work.
Once registered, complete the Shadow Health Orientation in the Shadow Health website/program and review the videos designed to assist with navigating and completing assignments.
Read the Shadow Health Nursing Documentation Tutorial located in the Week 1 Learning Resources.

Note: As nurses you typically use the word assessment to mean completing the physical exam. However, in the SOAP Note format, assessment means diagnosis so start getting in the habit of calling the physical exam exactly that.

Week 2 Case Studies

In Week 2, your Instructor will assign you a case study related to your Discussion by Day 1 of the week. Please make sure to review the “Course Announcements” area of the course to verify your assigned case study. Please plan ahead to ensure you have time to review your case study and your Learning Resources so that you can complete your Discussions and Assignments on time.

Photo Credit: Getty Images/iStockphoto

Next Module

To go to the next module:

Module 2

Initial Post: Obtaining a Health History

COLLAPSE

Obtaining a Health History

Obtaining a health history provides vital information regarding the patient’s current health status and previous diagnosis’ and treatment (Sullivan, 2019). This document is imperative to provide a foundation for the medical decisions and guidance to build from (Sullivan, 2019). As advanced practice registered nurses (APRNs) crucial to document a thorough health history, to best aid medical decision throughout the course of treatment and future visits. Failure to do so, or lack of important findings/information, may lead to insufficient care or misdiagnosis. Creating a safe environment for open communication can help the patient the feel relaxed and trusting, hopefully leading to good report with the provider.

Discussion: Building a Health History

Interview Description and Techniques Used

Patient Profile:

40-year-old black recent immigrant from Africa without insurance

Preceding the health interview, the patient’s vital signs, height and weight would be collected and reviewed by the APRN. Next the APRN should knock, wait for consent to enter. When given permission to enter, one must introduce his/herself while explaining the series of events that will occur, awaiting the patient’s permission. A quick assessment of language will help the provider know if he/she needs a certified interpreter. While conducting the interview, the provider should structure all questions as “Patient-Centered Questions”. Delivering the interview as patient-centered facilitates high quality care by incorporating the patient into the plan of care, allowing their wishes, needs, and cultural requirements to be considered and respected (Ball, 2019).

Discussion: Building a Health History

To improve patient responses to questions the APRN should be mindful of how the questions are phrased and be sure to ask one question at time, especially if the patient’s first language isn’t the same as the providers (Ball, 2019). Be sure to allow enough time between questions and respect pauses to avoid discouraging the patient from being complete in their response (Ball, 2019). When structuring a question, be sure to leave it open-ended. If more precise information is needed, provide a direct question, looking for specific information.

During the interview the APRN should be mindful of professionalism and body language. He/she should maintain eye contact, while reading body language of the patient to gage comfort level of the patient, and act accordingly, remain seated in front of the patient, not standing over them, provide privacy and ensure confidentiality, and maintain a professional dress code (Ball, 2019).

Discussion: Building a Health History

Explanation of techniques

Choosing to deliver the question in a patient-centered manner, will help establish good report through effective communication (Ball, 2019). Effective communication is built through courtesy, comfort, connection, and confirmation.

Courtesy

Showing common courtesy to a patient through asking permission, explain each step of a process, and common manners, can help a patient feel more secure. Being in a position as a provider, many patients feel this is a figure of authority and may feel vulnerable in your presents.

Comfort

When interviewing the patient, be sure you and patient are comfortable (Ball, 2019). Providing a comfortable environment can help decrease the amount of distraction that may hinder the patient from sharing their full story.

Connection

At the beginning of collecting the health history, always start with an open-ended question, such as: how have been? What brought you in today? Be mindful of the words you choose, avoiding demeaning phrases and medical terminology (Ball, 2019). The patient may not always share information with words. Be mindful of body language and ask questions appropriate to the observation.

Confirmation

At the end of the health history, be sure to summarize and clarify any areas that may been communicated unclearly. You should always leave an opportunity to share any further details about their medical, psychosocial, or financial situation that may be pertinent to the develop and guidance of the care plan. Asking “Is there anything else you’d like to add?” provides the patient the opportunity to share anything that may have been forgotten (Ball, 2019).

Discussion: Building a Health History

Risk Assessment Instrument

The risk assessment tool, I feel, is the most crucial for a new patient is SAD PERSONS scale. This scale was developed for medical students and non-psychiatric providers to help guide the possible risk of suicide in patients (Ng, How, &Ng, 2017). This is a mnemonic, where each positive answer is given one point (Ng et al., 2017). Scores of 3-4, the patient needs to be monitored. Scores of 5-6, strong consideration should be given to hospitalization. If the patient scores a 7 or greater, the patient must be admitted for further evaluation.

The acronym stands for:

Sex (male)

Age (<20 or >44)

Depression (history)

Previous suicide attempts

Ethanol abuse

Rational thinking loss (Psychosis)

Social support lacking

No spouse

Sickness (chronic or debilitating)

The worldwide rate of depression among migrates is approximately 15.6% (Foo et al., 2018). While this does not show a significant increase when compared to their native counterparts, the percentage does suggest a significant prevalence of depression throughout the migrant community. Those who have recently arrived and are unemployed, are more likely to experience depression (Foo et al., 2018)

This particular patient, recently moved their home country, where familiarity has been lost. Making a momentous decision, as to leave one’s home, may ignite feelings of regret and loneliness. Using the SAD PERSONS risk assessment will help the APRN properly evaluate the patient’s adjustment to the major life decision.

Discussion: Building a Health History

5 Targeted Questions

Tell me what brought you in today.
When did you move here?/how long have you been here?
Do you have any support at home?
Tell me how you are adjusting to your new environment
Are you experiencing any feelings of anxiety, depression, sadness, nervousness, anger etc.?

Conclusion

Collecting a full and comprehensive health history give the medical team a foundation to work from. APRNs should interview each new patient to obtain a detailed time line of the patient’s medical, psychosocial, and family history. Maintaining effective communication and asking patient-centered questions should help nurture good report with the patient. Every new patient should be screened for depression and suicide ideation, but those of vulnerable populations should be evaluated with each visit, until normalcy is established.

Discussion: Building a Health History

Resources

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Foo, S., Tam, W., Ho, C., Tran, B., Nguyen, L., Mcintyre, R., &; Ho, R. (2018). Prevalence of Depression among Migrants: A Systematic Review and Meta-Analysis. International Journal of Environmental Research and Public Health, 15(9), 1986. doi:10.3390/ijerph15091986

Ng, C., How, C., & Ng, Y. (2017). Depression in primary care: Assessing suicide risk. Singapore Medical Journal, 58(2), 72-77. doi:10.11622/smedj.2017006

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Week 1-Main Post

To gather a complete and comprehensive patient history and assessment, it is necessary to build rapport with the patient. To foster a healthy relationship with the adolescent patient, the physician should provide a private, comfortable space with minimum distractions. Allowing the patient to first learn about the provider’s history and beginning with small talk will assist establish a favorable tone and facilitate communication (Themes, 2019). As stated in the text, physicians should not make judgments about the ethnicity or cultural background of a patient (Ball et al., 2018). The healthcare provider may inquire about the patient’s self-perception and ethnic heritage. Even when the patient has inquired about contraceptives, current sexual activity cannot be assumed without an evaluation.

Discussion: Building a Health History
While 40% of teenagers in the United States receive annual medical examinations, just 5% of these visits address sexual and reproductive health and counseling (Santa Maria et al., 2017). The Centers for Disease Control and Prevention (CDC) acknowledges this as an area for improvement and recommends that pregnancy screening checklists be completed at each visit (Santa Maria et al., 2017). Determine the patient’s current and previous relationships, as well as their understanding of sexual activity and contraception. With roughly 88.2% of American women utilizing contraceptives, it is typically the nurse’s responsibility to deliver non-coercive, accurate, evidence-based patient education (Britton et al., 2020). To establish whether the patient’s demands are adequately satisfied during the visit, the following questions were formulated.

Have you ever visited a gynecologist? What do you know about sexual health and sexually transmitted diseases?

Are you in a relationship or are you sexually active?

When was your last period, and at what age did you begin menstruating? How many cycles have you experienced in the past year?

Tell me about your knowledge about birth control.

5. Are you interested in short-term or long-term contraception?

The provider must give proper counseling, services, and referrals, as well as educate the patient on safety, contraindications, failure rates, and fertility restoration.

Discussion: Building a Health History

References

Ball, J. Dains, J. Flynn, B. Solomon, R. Stewart, & J. Ball Dains (2018). An interdisciplinary approach to Seidel’s guide to physical examination (Mosby’s guide to physical examination) (9th ed.). Mosby.
Britton, L. E., A. Alspaugh, M. Z. Greene, and M. R. McLemore (2020). An update based on scientific evidence on contraception. 22–33. AJN, American Journal of Nursing, 120(2).
https://doi.org/10.1097/01.naj.0000654304.29632.a7
Santa Maria, D., Guilamo-Ramos, V., Jemmott, L. S., Derouin, A., & Villarruel, A. (2017).
On the front lines are nurses. 117(1), 42–51, American Journal of Nursing.
https://doi.org/10.1097/01.naj.0000511566.12446.45
U. Themes (2019, December 29). Filipino Americans. Nurse Key. https://nursekey.com/filipino-\samericans/

NURS_6512_Week_1_Discussion_Rubric

	Excellent	Good	Fair	Poor
Main Posting	Points Range: 45 (45%) – 50 (50%) “Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.	Points Range: 40 (40%) – 44 (44%) “Responds to the Discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.	Points Range: 35 (35%) – 39 (39%) “Responds to some of the Discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors.	Points Range: 0 (0%) – 34 (34%) “Does not respond to the Discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Post: Timeliness	Points Range: 10 (10%) – 10 (10%) Posts main post by Day 3.	Points Range: 0 (0%) – 0 (0%) N/A	Points Range: 0 (0%) – 0 (0%) N/A	Points Range: 0 (0%) – 0 (0%) Does not post main post by Day 3.
First Response	Points Range: 17 (17%) – 18 (18%) “Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.	Points Range: 15 (15%) – 16 (16%) “Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	Points Range: 13 (13%) – 14 (14%) “Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.	Points Range: 0 (0%) – 12 (12%) “Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Second Response	Points Range: 16 (16%) – 17 (17%) “Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.	Points Range: 14 (14%) – 15 (15%) “Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	Points Range: 12 (12%) – 13 (13%) “Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.	Points Range: 0 (0%) – 11 (11%) “Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Participation	Points Range: 5 (5%) – 5 (5%) Meets requirements for participation by posting on three different days.	Points Range: 0 (0%) – 0 (0%) N/A	Points Range: 0 (0%) – 0 (0%) N/A	Points Range: 0 (0%) – 0 (0%) Does not meet requirements for participation by posting on three different days.

Total Points: 100

Discussion: Building a Health History

NURS 6512 Week 1: Building a Comprehensive Health History