Taking a Health History: Building a Health History: Asking Difficult Questions
A careful and comprehensive history is vital before the examination of any patient. In addition to a good general history, focusing on the history of the presenting complaint enables the clinic to tailor the examination to elicit the appropriate signs and make an accurate diagnosis. The gynecology history taking and exam should always be conducted with appropriate privacy and sensitivity. The purpose of this paper is to present a script that will be used in my first encounter with a patient for a well-woman appointment.
Creating rapport
Hello. I am Ayeshia, and I will be examining you today. I believe you are here for your first well-woman appointment.
I will ask you several questions about your medical and sexual history, some of which might be uncomfortable. Your information will be confidential and not be shared with another person without your consent.
Demographic History
I will start by taking your personal information.
What is your name?
How old are you?
How would you describe your gender?
What is your address?
Medical history
I will then proceed to your general medical history.
Do you have any chronic illnesses?
What medications and supplements, prescribed or over-the-counter, are you taking, and what are their indications?
What food, drug, or environmental allergies do you have?
When was your last Tetanus and Influenza shot?
Which mental health disorders have you been diagnosed with currently or in the past? (Schuiling & Likis, 2022).
Substance Use History
I will ask you about your substance use.
Do you currently take alcohol, and if yes, how often and what amount?
Do you smoke, and if yes, how many packets per day?
Have you ever used illicit substances like marijuana, cocaine, or heroin?
Family Health History
Do you have family members with chronic illnesses?
Has any family member died from a chronic illness?
Which gynecologic disorders are present in your family members? (Schuiling & Likis, 2022)
SDOH
What is your current education level?
What is your occupation?
What is your income level?
What challenges do you experience accessing healthcare?
Do you have private or public-funded health insurance?
What is your marital status?
How many children do you have?
How often do you engage in physical exercises?
How would you describe your sleep pattern?
How many meals do you have daily, and what are your food preferences?
What challenges do you face in accessing healthy foods? (Ziso et al., 2022).
Have you encountered domestic abuse?
Have you ever been convicted?
Gynecologic Health History
I will now ask you questions about your reproductive and sexual health. This will include your menstruation, contraceptive use, sexual functioning, reproductive and obstetric history, and cancer screening (Aryal & Atreya, 2022).
Menstrual History
At what age did you have your first menses?
When was your last menstrual period?
How long is your menstrual cycle?
Is your menstrual cycle regular or irregular?
What is the duration of your menses? (Schuiling & Likis, 2022).
Do you experience very painful menses or excessive menstrual bleeding?
Do you experience clots or vaginal pooling during menses?
How many tampons or pads do you use per day during menses?
Do you experience spotting between menses or missed menses?
What premenstrual symptom do you experience, that is, 3-7 days before the onset of menses?
Contraceptive Use
Which contraceptives do you use?
How often do you use the said contraceptive?
Have you experienced any associated problems with birth control or STD- prevention methods like reaction to spermicides, diaphragms, or condoms? (Aryal & Atreya, 2022).
What problems have you experienced with hormonal contraceptive methods?
Have you ever considered using long-term contraceptive methods like implants or IUDs?
Sexual functioning
What is your sexual preference?
What unusual sexual interests do you have?
How many sexual partners do you have?
How would you rate your sexual satisfaction?
Do you experience pain during intercourse or delayed infrequent or absent orgasms? (Hagey et al., 2020).
Reproductive medical history
Have you previously been diagnosed with gynecological infections like yeast infections, salpingitis, endometritis, PID, or cervicitis?
Which STIs have you ever been diagnosed with?
How were the STIs treated? (Barrow et al., 2020).
Do you have a history of uterine fibroids or ovarian cysts?
Obstetric History
How many pregnancies have you had?
What were the dates of those pregnancies?
What was the outcome of the pregnancies (a live birth or a miscarriage)?
What complications did you experience during pregnancy, labor, delivery, and after delivery?
Reproductive Cancer Screening
When was your last self-breast exam?
What unusual findings did you find during the breast exam?
When was your last mammography?
When did you last have a pap smear?
What were the results of the Pap smear?
Reflection
Developing the script for building a health history for a well-woman exam was time-consuming. I learned that taking the patient’s general medical history is crucial since some medical conditions are comorbid with gynecological disorders (Park et al., 2020). The experience enlightened me that when taking a gynecologic history, the clinician should ask about the problem prompting the visit, sexual activities, past and present menstrual periods, past pregnancies, contraceptive use, and gynecologic symptoms, disorders, and treatments the client has had.
When undertaking the gynecology history, I may encounter difficulties asking clients about their sexual preference, orientation, number of sexual partners, interests, and satisfaction. It would also be difficult to ask patients about their history of STIs and STDs since most shy away from answering, and others give false information. I found it insightful that it is essential to ask about sexual identity and gender identity issues to allow clients to talk about these issues (Easpaig et al., 2022). Assuming a client’s sexual preference and orientation prevents LGBTQ patients from receiving better healthcare. When asking about sexual orientation and preferences, I would use neutral and inclusive terms like “partner” and ask the questions non-judgmentally. If the patient appears offended or reluctant to answer, I would briefly explain why I am asking the question.
Access to healthy, nutritious foods is a major challenge for Americans, especially those with low-income levels. This contributes to the high prevalence of chronic diseases. Low-income and minority communities often lack suitable places that offer affordable, healthier foods. As an NP, I would support farm-to-institution programs in my community to connect community members to healthier foods (Ziso et al., 2022). I would also connect local food hubs to organizations that sell healthy foods in low-income communities.
References
Aryal, S., & Atreya, A. (2022). History taking in gynecology revisited. Acta bio-medica : Atenei Parmensis, 92(6), e2021554. https://doi.org/10.23750/abm.v92i6.11940
Barrow, R. Y., Ahmed, F., Bolan, G. A., & Workowski, K. A. (2020). Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020. MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports, 68(5), 1–20. https://doi.org/10.15585/mmwr.rr6805a1
Easpaig, B. N. G., Reynish, T. D., Hoang, H., Bridgman, H., Corvinus-Jones, S. L., & Auckland, S. (2022). A systematic review of the health and health care of rural sexual and gender minorities in the UK, USA, Canada, Australia, and New Zealand. Rural and Remote Health, 22(3), 1–16. https://doi.org/10.22605/RRH6999
Hagey, J. M., Toole, J., Branford, K., Reynolds, T., Livingston, E., & Dotters-Katz, S. K. (2020). Understanding Sexual Complaints and History Taking: A Standardized Patient Case on Dyspareunia for Obstetrics and Gynecology Clerkship Students. MedEdPORTAL: the journal of Teaching and learning resources, p. 16, 11001. https://doi.org/10.15766/mep_2374-8265.11001
Park, K., Wu, P., & Gulati, M. (2020). Obstetrics and Gynecological History: A Missed Opportunity for Cardiovascular Risk Assessment. JACC. Case reports 2(1), 161–163. https://doi.org/10.1016/j.jaccas.2019.11.035
Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.
Ziso, D., Chun, O. K., & Puglisi, M. J. (2022). Increasing Access to Healthy Foods through Improving Food Environment: A Review of Mixed Methods Intervention Studies with Residents of Low-Income Communities. Nutrients, 14(11), 2278. https://doi.org/10.3390/nu14112278
