Conduct a health history on a family member or friend. You can use the form located in your Health Assessment lab manual book or from Week Two classroom assignment.You do not need to submit the health history form with your paper. Be sure they give you permission. Using the interviewing techniques learned in Module 2, gather the following information. Use your textbook as your guide. · Present Health · Past Medical Health · Family History · Review of Systems While this is only a partial health history, summarize in 3 -5 pages the information you gathered. Include your answers to the following questions in the summary: 1. Was the person willing to share the information? If they were not, what did you do to encourage them? 2. Was there any part of the interview that was more challenging? If so, what part and how did you deal with it? 3. How comfortable were you taking a health history? 4. What interviewing techniques did you use? Were there any that were difficult and if so, how did you overcome the difficulty? 5. Now that you have taken a health history discuss how this information can assist the nurse in determining the health status of a client. NUR2092 WRITE-UP—HEALTH HISTORY Classroom Assignment Week Two Date ___4/16/22____________ Examiner _ __________ 1. Biographic Data Name: ___ _____________________________________ Phone_________________ Address__ Il_________________ Birthdate ________________________________ Birthplace ______ ________ Age __37________ Gender _____Male_____ Marital Status _Married _____________ Occupation __Independent Contractor________ Race/ethnic origin __ _____________________ Employer __ __________________ 2. Source and Reliability: From Patient 3. Reason for Seeking Care: Annual medical check-up 4. Present Health or History of Present Illness: None Past Health Describe general health __Good____________________________________________________ Childhood illnesses ____None____________________________________________________________ Accidents or injuries (include age) ___None________________________________________________ Serious or chronic illnesses (include age) _None______________________________________________ Hospitalizations (what for? location?) ___None_______________________________________________ Operations (name procedure, age) _____None_______________________________________________ Obstetric history: Gravida __N/A__________ Term ___N/A_________ Preterm ___N/A_________ (# Pregnancies) (# Term pregnancies) (# Preterm pregnancies) Ab/incomplete _N/A____________________ Children living _____N/A________________ (# Abortions or miscarriages) _N/A____ Course of pregnancy____N/A____________________________________________________________ (Date delivery, length of pregnancy, length of labor, baby’s weight and sex, vaginal delivery or cesarean section, complications, baby’s condition) Immunizations: _Up to date immunization____________________________________________ Last examination date: Physical __ ...

1. Conduct a health history on a family member or friend. You can
use the form located in your Health Assessment lab manual
book or from Week Two classroom assignment.You do not need
to submit the health history form with your paper. Be sure they
give you permission. Using the interviewing techniques learned
in Module 2, gather the following information. Use your
textbook as your guide.
· Present Health
· Past Medical Health
· Family History
· Review of Systems
While this is only a partial health history, summarize in 3 -5
pages the information you gathered.
Include your answers to the following questions in the
summary:
1. Was the person willing to share the information? If they were
not, what did you do to encourage them?
2. Was there any part of the interview that was more
challenging? If so, what part and how did you deal with it?
3. How comfortable were you taking a health history?
4. What interviewing techniques did you use? Were there any
that were difficult and if so, how did you overcome the
difficulty?
5. Now that you have taken a health history discuss how this
information can assist the nurse in determining the health status
of a client.
NUR2092 WRITE-UP—HEALTH HISTORY
Classroom Assignment Week Two
Date ___4/16/22____________ Examiner _ __________
1. Biographic Data Name: ___

2. _____________________________________
Phone_________________ Address__ Il_________________
Birthdate ________________________________ Birthplace
______ ________ Age __37________ Gender _____Male_____
Marital Status _Married _____________ Occupation
__Independent Contractor________ Race/ethnic origin __
_____________________ Employer __ __________________
2. Source and Reliability: From Patient
3. Reason for Seeking Care: Annual medical check-up
4. Present Health or History of Present Illness: None
Past Health
Describe general health
__Good______________________________________________
______ Childhood illnesses
____None____________________________________________
________________ Accidents or injuries (include age)
___None_____________________________________________
___ Serious or chronic illnesses (include age)
_None______________________________________________
Hospitalizations (what for? location?)
___None_____________________________________________
__ Operations (name procedure, age)
_____None___________________________________________
____
Obstetric history: Gravida __N/A__________ Term
___N/A_________ Preterm ___N/A_________ (# Pregnancies)
(# Term pregnancies) (# Preterm pregnancies)
Ab/incomplete _N/A____________________ Children living
_____N/A________________ (# Abortions or miscarriages)
_N/A____
Course of
pregnancy____N/A_____________________________________

3. _______________________ (Date delivery, length of
pregnancy, length of labor, baby’s weight and sex, vaginal
delivery or cesarean section, complications, baby’s condition)
Immunizations: _Up to date
immunization_________________________________________
___
Last examination date: Physical ________________
Dental ____9/_14/2021___________ Vision
__11/17/2021________ Allergies __None____________
Reaction ___None_________________________
Current medications
___None___________________________________________ _
6. Family History—Specify Which Relative(s)
Heart disease: _None_______________________ High blood
pressure: _Father_____________
Stroke: _Father______________________ Diabetes: ___None
____________________________
Blood disorders: _______None _______________ Breast or
ovarian cancer: ____None________
Cancer (other): ____None______________________ Sickle
cell: __None __________________
Arthritis: ____None_____________________
Allergies: ____None___________________________ Asthma:
None __________________
____ Obesity: ___None____________________________
Alcoholism or drug addiction _None _____________
Mental illness _None____________________ Suicide
___None____________________________
Seizure disorder __N/A______________________ Kidney
disease __N/A________________________ Tuberculosis
_N/A____
Review of Systems (Circle/highlight both past health problems

4. that have been resolved and current problems, including date of
onset.)
General Overall Health State: Present weight (gain or loss,
period of time, by diet or other factors), fatigue, weakness or
malaise, fever, chills, sweats or night sweats. None
Skin: History of skin disease (eczema, psoriasis, hives),
pigment or color change, change in mole, excessive dryness or
moisture, pruritus, excessive bruising, rash or lesion: None
Hair: Recent loss, change in texture: None
Nails: Change in shape, color, or brittleness: None
Health Promotion: Amount of sun exposure, method of self-care
for skin and hair: N/A
Head: Any unusually frequent or severe headache, any head
injury, dizziness (syncope), or vertigo: None
Eyes: Difficulty with vision (decreased acuity, blurring, blind
spots), eye pain, diplopia (double vision), redness or swelling,
watering or discharge, glaucoma or cataracts: None
Health Promotion Eyes: Wears glasses or contacts, last vision
check or glaucoma test, how coping with loss of vision, if any:
None
Ears: Earaches, infections, discharge and its characteristics,
tinnitus, or vertigo: None
Health Promotion Ears: Hearing loss, hearing aid use, how loss
affects daily life, any exposure to environmental noise, method
of cleaning ears: None
Nose and Sinuses: Discharge and its characteristics, any
unusually frequent or severe colds, sinus pain, nasal
obstruction, nosebleeds, allergies or hay fever, or change in
sense of smell: None
Mouth and Throat: Mouth pain, frequent sore throat, bleeding
gums, toothache, lesion in mouth or tongue, dysphagia,
hoarseness or voice change, tonsillectomy, altered taste: None

5. Health Promotion/Mouth & Throat: Pattern of daily dental care,
use of prostheses (dentures, bridge), and last dental checkup:
None
Neck: Pain, limitation of motion, lumps or swelling, enlarged or
tender nodes, goiter: None
Breast: Pain, lump, nipple discharge, rash, history of breast
disease, any surgery on breasts Axilla: Tenderness, lump or
swelling, rash: N/A
Health Promotion Breast: Performs breast self-examination,
including frequency and method used, last mammogram and
results: N/A
Respiratory System: History of lung disease (asthma,
emphysema, bronchitis, pneumonia, tuberculosis), chest pain
with breathing, wheezing or noisy breathing, shortness of
breath, how much activity produces shortness of breath, cough,
sputum (color, amount), hemoptysis, toxin or pollution exposure
Health Promotion Respiratory: Last chest x-ray examination:
None
Cardiovascular System: Precordial or retrosternal pain,
palpitation, cyanosis, dyspnea on exertion (specify amount of
exertion it takes to produce dyspnea), orthopnea, paroxysmal
nocturnal dyspnea, nocturia, edema, history of heart murmur,
hypertension, coronary artery disease, anemia
Health Promotion Cardiovascular: Date of last ECG or other
heart tests and results: None
Peripheral Vascular System: Coldness, numbness and tingling,
swelling of legs (time of day, activity), discoloration in hands
or feet (bluish red, pallor, mottling, associated with position,
especially around feet and ankles), varicose veins or
complications, intermittent claudication, thrombophlebitis,
ulcers Health Promotion Peripheral Vascular: If work involves
long-term sitting or standing, avoid crossing legs at the knees;
wear support hose.
None
Gastrointestinal System: Appetite, food intolerance, dysphagia,

6. heartburn, indigestion, pain (associated with eating), other
abdominal pain, pyrosis (esophageal and stomach burning
sensation with sour eructation), nausea and vomiting
(character), vomiting blood, history of abdominal disease
(ulcer, liver or gallbladder, jaundice, appendicitis, colitis),
flatulence, frequency of bowel movement, any recent change,
stool characteristics, constipation or diarrhea, black stools,
rectal bleeding, rectal conditions, hemorrhoids, fistula)
Health Promotion Gastrointestinal: Use of antacids or laxatives:
None
Urinary System: Frequency, urgency, nocturia (the number of
times awakens at night to urinate, recent change), dysuria,
polyuria or oliguria, hesitancy or straining, narrowed stream,
urine color (cloudy or presence of hematuria), incontinence,
history of urinary disease (kidney disease, kidney stones,
urinary tract infections, prostate); pain in flank, groin,
suprapubic region, or low back: None
Health Promotion Urinary: Measures to avoid or treat urinary
tract infections, use of Kegel exercises: None
Male Genital System: Penis or testicular pain, sores or lesions,
penile discharge, lumps, hernia: None
Health Promotion Male Genital: Perform testicular self-
examination? How frequently?
None
Female Genital System: Menstrual history (age at menarche,
last menstrual period, cycle and duration, any amenorrhea or
menorrhagia, premenstrual pain or dysmenorrhea,
intermenstrual spotting), vaginal itching, discharge and its
characteristics, age at menopause, menopausal signs or
symptoms, postmenopausal bleeding. N/A
Health Promotion Female Genital: Last gynecologic checkup,
last Pap test and results; N/A
Sexual Health: Presently in a relationship involving
intercourse? Yes. Are aspects of sex satisfactory to you and
partner? Yes. any dyspareunia (for female), any changes in

7. erection or ejaculation (for male) None. use of contraceptive, is
contraceptive method satisfactory? N/A. Use of condoms, how
frequently? None. Aware of any contact with partner who has
sexually transmitted infection (gonorrhea, herpes, chlamydia,
venereal warts, HIV/AIDS, syphilis)? None
Musculoskeletal System: History of arthritis or gout. In the
joints: pain, stiff-ness, swelling (location, migratory nature),
deformity, limitation of motion, noise with joint motion. In the
muscles: any pain, cramps, weakness, gait problems or problems
with coordinated activities. In the back: any pain (location and
radiation to extremities), stiffness, limitation of motion, or
history of back pain or disk disease. None
Health Promotion Musculoskeletal: How much walking per day?
2 miles What is the effect of limited range of motion on daily
activities, such as on grooming, feeding, toileting, dressing?
None. Any mobility aids used? None
Neurologic System: History of seizure disorder, stroke, fainting,
blackouts. In motor function: weakness, tic or tremor, paralysis,
coordination problems. In sensory function: numbness and
tingling (paresthesia). In cognitive function: memory disorder
(recent or distant, disorientation). In mental status: any
nervousness, mood change, depression, or any history of mental
health dysfunction or hallucinations. None
Hematologic System: Bleeding tendency of skin or mucous
membranes, excessive bruising, lymph node swelling, exposure
to toxic agents or radiation, blood transfusion and reactions.
Endocrine System: History of diabetes or diabetic symptoms
(polyuria, polydipsia, polyphagia), history of thyroid disease,
intolerance to heat or cold, change in skin pigmentation or
texture, excessive sweating, relationship between appetite and
weight, abnormal hair distribution, nervousness, tremors, need
for hormone therapy. None
Functional Assessment (Including Activities of Daily Living)
Self-Esteem, Self-Concept: Education (last grade completed,
other significant training) __University____________
Financial status (income adequate for lifestyle and/or health

8. concerns) __________
Value-belief system (religious practices and perception of
personal strengths) ___________
Self-care behaviors _Eating a good balance diet and very
active_____________________
Activity and Exercise: Daily profile, usual pattern of a typical
day __Exercise once in a week by walking 2 miles
______________________
Independent or needs assistance with ADLs, feeding, bathing,
hygiene, dressing, toileting, bed-to-chair transfer, walking,
standing, climbing stairs
___None______________________________
Leisure activities ____Spend time with
family____________________________________
Exercise pattern (type, amount per day or week, method of
warm-up session, method of monitoring: Walking
Sleep and Rest: Sleep patterns, daytime naps, any sleep aids
used __None_________________
Nutrition and Elimination: Record 24-hour diet recall. __No
diet restriction _____________________________________
_____________________________________________________
________________________________
Is this menu pattern typical of most days?
___________________________________________________
Who buys food? __The Patient buy his
food__________________________
Who prepares food? ___The patient’s wife prepares the food
and the patient assist in the kitchen______________________
Finances adequate for food?
___Yes_______________________________
Who is present at mealtimes? __The patient
________________________________
Interpersonal Relationships and Resources: Describe own role
in family __Father_______________________
How getting along with family, friends, co-workers, classmates
_Patient get along very well with friends and

9. family_____________________
Get support with a problem from? ____wife
__________________________________________
How much daily time spent alone? ____None spent most time
with family_______________________ Is this pleasurable or
isolating?
Pleasurable___________________________________________
_
Coping and Stress Management: Describe stresses in life now
__Combining work and family together
________________________________
_____________________________________________________
________________________________ Change(s) in past year
______None________________________________________
Methods used to relieve stress __relaxing and
movie_____________________
Are these methods helpful? _Yes__________________________
Personal Habits:
Daily intake caffeine (coffee, tea, colas)
__None____________________________________
Smoke cigarettes? ___None________________ Number packs
per day ___None___________
Daily use for how many years ___N/A___________ Age started
__N/A_________
Ever tried to quit? __N/A__________________ How did it go?
___N/A___________________
Drink alcohol? _No__________________ Date of last alcohol
use __N/A_____
Amount of alcoholthat episode
______N/A___________________________________________
_________
Out of last 30 days, on how many days had alcohol?
____________________________________
Ever told had a drinking problem?
__No________________________________________________
__ Any use of street drugs? __None______Marijuana?

10. _None________________________________
Cocaine? ____None______________________________ Crack
cocaine? __N/A__________________ Amphetamines?
__N/A______________ Heroin? ____N/A______________
Prescription painkillers? ___N/A____________ Barbiturates?
___N/A____________________________ LSD?
____N/A_________________________________
Ever been in treatment for drugs or alcohol?
__N/A______________________________________________
Environment and Hazards: Housing and neighborhood (type of
structure, live alone, know neighbors) _City, Live with family
_____________________________________________________
_______________________________
Safety of area
___Good_____________________________________________
___________________ Adequate heat and utilities
_____Good___________________________________________
________
Access to transportation
____Yes_____________________________________________
___________
Involvement in community services
___No_______________________________________________
__ Hazards at workplace or home
___None_____________________________________________
______ Use of seatbelts
_______Yes__________________________________________
___________________
Travel to or residence in other countries
___No_____________________________________________
Military service in other countries ___No_______________
Self-care behaviors _______________ Intimate Partner
Violence: None How are things at home? Good Do you feel
safe?___Yes____________
Ever been emotionally or physically abused by your partner or
someone important to you: __No_-

11. Ever been hit, slapped, kicked, pushed, or shoved or otherwise
physically hurt by your partner or ex-partner?
No__________________________________________________
____________________________ Partner ever force you into
having sex?
_No__________________________________________ Are you
afraid of your partner or ex-partner?
____No____________________________
Occupational Health:
Please describe your job. ___Independent
Contractor___________________________
Work with any health hazards (e.g., asbestos, inhalants,
chemicals, repetitive motion)?
_________________No_________________________________
_________________________________
Any equipment at work designed to reduce your exposure? No
Any work programs designed to monitor your exposure?
____No_____________________________
Any health problems that you think are related to your job?
__No___________________________
What do you like or dislike about your job? ___I like the fact
that is flexible for me _________________
Perception of Own Health:
How do you define health? _My health has been good so
far_________________________
View of own health now __No major illness which I’m happy
about. Everything looks
perfect_______________________________________________
_______________
What are your concerns? __None
_____________________________________________________
_________
What do you expect will happen to your health in future?
___considering the fact that I don’t have any underlying illness,
I expect to be healthy in future like I am right now.
____________________

12. Your health goals __continue to maintain my weight, eat more
of healthy food to keep
healthier_____________________________________________
_______________________
Your expectations of nurses, physicians _I expect the nurse and
physicians to responds to my concerns/ needs when needed and
also continue to treat all the patient with respect and love like
they have been doing
__________________________________________________