Obtain and Record Client History

The primary objectives are:

  • To obtain client’s personal and social data and information on health status
  • To identify abnormalities/problems requiring treatment or referral

For FP clients, it is important to pay particular attention to information outlined in the table below:

HISTORY INFORMATION NEEDED
Social History
  • Smoking? How many cigarrettes per
    day?
  • Drinking? How much alcohol per day?
Family Health
History
  • Diabetes mellitus, high blood
    pressure, asthma, heart disease
Personal
Medical History
  • Excessive weight gain/loss (+/- 5 kg/
    year)
  • Severe headaches (relieved by
    analgesics?)
  • Growth on neck (enlarged thyroid)
  • Current or past diseases: asthma,
    cardiac disease, high BP, diabetes
    mellitus, mental illness, epilepsy,
    thrombophlebitis, varicose veins,
    unilateral pain in thighs or calves,
    chronic anaemia (e.g. sickle-cell
    anaemia), liver disease/jaundice in
    the last 6 months or during pregnancy
  • TB (on treatment?)
  • Allergies
  • Any medicines being taken and
    reason
Surgical
History
  • Any previous or planned operations
  • Where and when operation was
    performed, or is to be performed
Reproductive
History
  • Total pregnancies
  • Number and sex of live children
  • Number of abortions/ miscarriages
  • Number of children who died
  • Age of youngest child
  • Type of delivery for her children
  • Any problems in previous pregnancy
    or deliveries
  • Number of children desired
  • When does she wish to have next child
  • Whether breastfeeding
Menstrual
History
  • Age at onset of menstruation
  • Length of cycles
  • Periods regular or not?
  • Number of days and amount of blood
    loss
  • Bleeding after intercourse
  • Date and length of last normal period
Gynaecological
History
  • Vulval sores or warts
  • PID and STI? If yes, which one, was it
    treated and when?
  • Lower abdominal pain
  • Offensive vaginal odour/discharge
  • Pain during intercourse
  • Pain on urination
  • Bleeding between periods
Family
Planning
History
  • How/where first learned about FP
  • Whether new to FP, or used FP before
  • If used before, which method used
  • Age when started using FP

Last FP method used:

  • Duration of using each FP method
    used
  • Reasons for discontinuation of FP
  • Currently preferred method
Inform Client
  • If chosen method seems suitable or
    contraindicated
  • Explain that physical assessment will
    confirm suitability of this method
  • Next steps needed