DemographicsInitials, age, raceethnicity, gender, occupation. .docx

Demographics
Initials, age, race/ethnicity, gender, occupation. Include a
sentence of who is providing the health history.
Perception of Health
Provide the client’s perception of health—include what they
stated in quotation marks.
Past Medical History
Include the client’s past medical history
Family Medical History
Include medical history for mother, father, siblings, maternal
and paternal grandparents
Continue documenting the health history as described in the
RUA guidelines and from the information in chapter 4 of your
text. I advise using headings, to ensure that you address all
components of the assignment. When you get to the review of
systems, it can be documented this way, for example:
Review of Systems
Head
Denies history of trauma, states frequent headaches for the last
3 weeks, occurring daily in the afternoon (this is an example—
you document what your client told you)
Skin
Denies history of eczema, psoriasis, rashes. States freckles on
cheeks and nose (again—document what your client told you)
Eyes
Continue as before. If the client does not have any concerns,
document denies _______, ________, and ______, using the
information from chapter 4 to guide you in the specific
questions to ask regarding each body system.
1
Running head: HEALTH HISTORY
5

HEALTH HISTORY
Health History
Samantha Candela
Chamberlain College of Nursing
NR 302: Health Assessment
2/12/2016
Professor Moersch
Health History Assessment
I choose to do a health assessment on a family friend. I
will use AH has her initials.
Demographic Data
AH is 63 years old, a female, Caucasian, and lives in a
house. She lives in a rural area where she lives alone but has
family close by.
Perception of Health
To her healthy means being in good health, getting regular
exercise, and eating nutritious food. Unhealthy to her means not
being in good health, overweight, and eating bad foods. She
feels like she is between healthy and unhealthy. She is not in

the best health, exercises once a week, and eats good most of
the time. She would like to increase her health and the amount
of exercise she gets.
Past Medical History
Her past medical history includes degenerative disc
disease, high blood pressure, hyperlipemia, depression, anxiety,
COPD, asthma, emphysema, diverticulitis, and osteoporosis.
Her past surgical history includes neck and back surgery,
removal of gallbladder, removal of cataract, and hysterectomy.
The medications she takes daily include a Spiriva inhaler,
allegra, valium, Zoloft, gabapentin, Lopressor, and protonix.
Family Medical History
Both of her parents had high blood pressure, which lead to
her high blood pressure. Her mother had asthma, which
increased her chance of having it. Her father had lung cancer
from smoking cigarettes. Her mother was anemic and had to
have a lot of blood transfusions.
Review of Systems
The only skin issue that she has is eczema. Her hair has
some grey in it and her nails are fine. She doesn’t have any
headaches, head injury, or dizziness. She has some pain in her
neck when she turns her head to the right. She doesn’t have any
lymphatic issues. She has decreased vision and had some
cataracts. She wears eyeglasses and had cataract removal
surgery in June 2015. She doesn’t have any earaches or
infections and her hearing is good. She has allergies to pollen
and dust but no other major sinus issue. Her mouth and throat
look good, no mouth pain, sore throat, toothaches, or lesions.
She has asthma and emphysema, which causes her to have
shortness of breath. Even with her breathing problems she can
still take care of herself, cook, and clean. Her only heart related
use is high blood pressure and she controls that with medication
and controls her salt intake.
Developmental Considerations
She has had asthma since she was a little girl and this has
caused her some issues growing up. She couldn’t play sports

and play with friends for long because she would start having
trouble breathing. She did not have many friends growing up
and had trouble with weight; she always thought that her asthma
caused this.
Cultural Considerations
Growing up she was always interested in going to church
but her family wasn’t very religious. She always wanted to
study her bible and her father would always have mean
comments to say to her. This made it hard for her to go to
church and be able to have a religious connection.
Psychosocial Considerations
She lost her husband almost a year ago and has had trouble
with wanting to be social. She doesn’t like to attend social
events because that was something her and her husband always
used to do together. Her children are great about coming to visit
her. At least one of them comes by daily and they have a weekly
family night.
Collaborative Resources
Her family helps her by visiting everyday and going to any
doctor appointments with her. She has a group of friends that go
to church every Sunday together then go to lunch afterward. Her
neighbor and her get together a few days of the week and walk
to get exercise.
Reflection
This interaction helped me to practice some of the skills I
learned in health assessment. We were able to talk about her
medical history well since I know a lot of the medical terms and
she also does because of how much she has had to be at
hospitals. During the review of systems she had trouble
understanding some of the questions I asked but we overcame it
by me explaining each subject. I now realized I should have
asked her more about any cultural issues.

References
American Psychological Association. (2010). Publication
manual of the American Psychological Association (6th ed.).
Washington, DC: Author.
Jarvis, C., Tarlier, D., Pelt, L. V., Andrews, M. E., & Jarvis, C.
(n.d.). Physical examination and health assessment (7th ed.).
Health History Worksheet
This worksheet is used to assist the student in gathering and
organizing information
when conducting a health history.
Family Member Description
Paternal grandfather
First and last initials: L. M.
Birthdate: April 11 1916
Death date: April 1984
Occupation: Private business man
Education: some college
Primary language: English
Health summary: passed from lymphoma and lung cancer
Paternal grandmother
First and last initials: C. M.

Birthdate: May 20 1919
Death date: December 1980
Occupation: House wife
Education: high school
Health summary: passed from aneurism
Father
First and last initials: W. M.
Birthdate: October 25 1959
Death date: Alive
Occupation: Failure Analysis Engineer at NASA
Education: Bachelors from Mississippi State
Health summary: Severe neck Arthritis
Father’s siblings- Summary of any significant
health issues
One sibling with cancer, one sibling with
fibromyalgia
Maternal grandfather
First and last initials: Unknown
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Maternal grandmother
First and last initials: E. V.
Birthdate: June 1940
Death date: August 1978

Education: none
Primary language: Spanish
Health summary: passed from Stomach cancer
Mother
First and last initials: R. V. M.
Birthdate: July 1 1961
Death date: Alive
Occupation: house wife
Education: Some high school
Health summary: No health conditions
Mother’s siblings- Summary of any significant
health issues No health conditions
Adult Participant
First and last initials: B.M.
Death date: Alive
Occupation: Student
Education: College
Health summary: No serious health conditions
Adult participant’s siblings Summary of any
significant health issues None
Adult participant’s spouse/significant other
First and last initials: N/A
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:

Adult participant’s children- Up to 4 children N/A
Child #1 first and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:

Father
Death date: Alive
health issues
fibromyalgia

Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Education: none
Mother
Death date: Alive
Adult Participant
Death date: Alive
Occupation: Student
Education: College

Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Birthdate:
Death date:

Occupation:
Education:
Primary language:
Health summary:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Father

Death date: Alive
health issues
fibromyalgia
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Education: none
Mother
Death date: Alive

Adult Participant
Death date: Alive
Occupation: Student
Education: College
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Birthdate:
Death date:
Occupation:
Education:

Primary language:
Health summary:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
An example
First and last initials: RL
Birthdate: 1921
Death date: 1981
Occupation: Retired as a coal miner

Education: 6th grade
Health summary:
He was diagnosed with chronic lung disease,
diabetes, and hypertension. He died from a
heart attack.
First and last initials: ML
Birthdate: 1932
Death date: 1998
Education: Does not want to disclose
Health summary: Diagnosed with chronic lung disease from
smoking cigarettes. Died from heart failure.
This example points to common problems among this generation
on both sides of the
Adult Participant’s family. Consider the potential implications
this would have for the
Adult Participant’s health status.
Original Date:

Dates Revised:
enter text.
enter text.
enter text.
enter text.
HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly
confidential
and will become part of your medical record.
Initials:
Race/Ethnicity:
☐M ☒
Age
Occupation: Student
Marital status:
☒ Single ☐ Partnered ☐ Married ☐ Separated ☐
Divorced ☐ Widowed

Reason for visit: Physical assessment
Perception of health:enter text.
Date of last physical exam:
8/22/2018
Source of information: enter text.
Reason for seeking care: Physical Assessment
Present health or history of present illness:
P
enter text.
Q
enter text.
R
enter text.
S
enter text.
T

enter text.
PERSONAL HEALTH HISTORY/Past health
Childhood illness:
◻ Measles ◻ Mumps ◻ Rubella ◻ Chickenpox ◻
Rheumatic Fever ◻ Polio
Immunizations and dates:
☒Tetanus
Up to date
☒Pneumonia
Up to date
☒Hepatitis
Up to date
☒Chickenpox
Up to date

☒Influenza
Up to date
☒MMR Measles, Mumps, Rubella
Up to date
List any medical problems that other doctors have diagnosed
N/A
Surgeries
Year
Reason
Hospital
N/A
enter text.
enter text.

enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
Other hospitalizations
Year
Reason
Hospital
N/A
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.

enter text.
enter text.
Have you ever had a blood transfusion?
☐
Yes
☒
No
Please turn to next page
List your prescribed drugs and over-the-counter drugs, such as
vitamins and inhalers
Name the Drug
Strength
Frequency Taken and Reason
Claritin
enter text.
1 or 3 times per week
enter text.
enter text.

enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.
enter text.

enter text.
Allergies to medications, latex, food, iodine/betadine
Name the Drug
Reaction You Had
N/A
enter text.
enter text.
enter text.
enter text.
enter text.
HEALTH HABITS AND PERSONAL SAFETY
All questions contained in this questionnaire are optional and
will be kept strictly confidential.
Exercise
☐Sedentary (No exercise)

☐Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
☐Occasional vigorous exercise (i.e., work or recreation, less
than 4x/week for 30 min.)
☒Regular vigorous exercise (i.e., work or recreation 4x/week
for 30 minutes)
Diet
Are you dieting?
☐
Yes
☒
No
If yes, are you on a physician prescribed medical diet?
☐
Yes
☐
No

# of meals you eat in an average day? Click or tap here to enter
text.
Rank salt intake
☐Hi
☐Med
enter text.Low
Rank fat intake
☐Hi
☐Med
enter text.Low
Caffeine
◻ None
☒Coffee
☐Tea
Coke Cola

# of cups/cans per day? 1 cup/day
Alcohol
Do you drink alcohol?
☒
Yes
☐
No
If yes, what kind? Beer
How many drinks per week? 1 per week
Are you concerned about the amount you drink?
☐
Yes
☒
No

Have you considered stopping?
☐
Yes
☒
No
Have you ever experienced blackouts?
☐
Yes
☒
No
Are you prone to “binge” drinking?
☐
Yes
☒
No

Do you drive after drinking?
☐
Yes
☒
No
Tobacco
Do you use tobacco?
☐
Yes
☒
No
☐Cigarettes – pks./day enter text.o
☐Chew - #/day enter text.
☐Pipe - #/day enter text.
☐Cigars - #/day enter text.
☐ # of years enter text.

☐Or year quit enter text.
Drugs
Do you currently use recreational or street drugs?
☐
Yes
☒
No
Have you ever given yourself street drugs with a needle?
☐
Yes
☒
No
Sex
Are you sexually active?
☒
Yes
☐

No
If yes, are you trying for a pregnancy?
☐
Yes
☒
No
If not trying for a pregnancy list contraceptive or barrier
method used: birth control
Any discomfort with intercourse?
☐
Yes
☒
No
Illness related to the Human Immunodeficiency Virus (HIV),
such as AIDS, has become a major public health problem. Risk

factors for this illness include intravenous drug use and
unprotected sexual intercourse. Would you like to speak with
your provider about your risk of this illness?
☐
Yes
☒
No
Personal Safety
Do you live alone?
☐
Yes
☒
No

Do you have frequent falls?
☐
Yes
☒
No
Do you have vision or hearing loss?
☒
Yes
☐
No
Do you have an Advance Directive and/or Living Will?
☐
Yes
☒
No

Would you like information on the preparation of these?
☐
Yes
☒
No
Physical and/or mental abuse have also become major public
health issues in this country. This often takes the form of
verbally threatening behavior or actual physical or sexual abuse.
Would you like to discuss this issue with your provider?
☐
Yes
☒

No
FAMILY HEALTH HISTORY
Age
Significant Health Problems
Age
Significant Health Problems
Father
60
Arthritis
Children
☐M
☐ F
N/A
Mother

56
N/A
☐M
☐ F
N/A
Sibling
☒M 23 years old
☐ F
N/A
☐M
☐ F
N/A
☐M
☐ F

N/A
☐M
☐ F
N/A
☐M
☐ F
N/A
Grandmother
Maternal
passed from Stomach cancer in 1978
☐M
☐ F

N/A
Grandfather
Maternal
enter text.
unknown
☐ M
☐ F
N/A
Grandmother
Paternal
enter text.
passed from aneurysm in 1980
☐M
☐ F
N/A
Grandfather

Paternal
enter text.
passed from lymphoma and lung cancer in 1984
MENTAL HEALTH
Comments
Is stress a major problem for you?
☐
Yes
☐
No
Do you feel depressed?
☐
Yes
☐
No

Do you panic when stressed?
☐
Yes
☐
No
Do you have problems with eating or your appetite?
☐
Yes
☐
No
Do you cry frequently?
☐
Yes
☐
No

Have you ever attempted suicide?
☐
Yes
☐
No
Have you ever seriously thought about hurting yourself?
☐
Yes
☐
No
Do you have trouble sleeping?
☐
Yes
☐
No

Have you ever been to a counselor?
☐
Yes
☐
No
WOMEN ONLY
Age at onset of menstruation: 12.
Date of last menstruation: May 15, 2019
Period every 28 days
Heavy periods, irregularity, spotting, pain, or discharge?
☐
Yes
☐
No

Number of pregnancies enter text. Number of live births enter
text.
Are you pregnant or breastfeeding?
☐
Yes
☐
No
Have you had a D&C, hysterectomy, or Cesarean?
☐
Yes
☐
No
Any urinary tract, bladder, or kidney infections within the last
year? UTI
☐
Yes
☐
No
Any blood in your urine?

☐
Yes
☐
No
Any problems with control of urination?
☐
Yes
☐
No
Any hot flashes or sweating at night?
☐
Yes
☐
No
Do you have menstrual tension, pain, bloating, irritability, or
other symptoms at or around time of period?
☐
Yes
☐

No
Experienced any recent breast tenderness, lumps, or nipple
discharge?
☐
Yes
☐
No
Date of last pap and rectal exam? 2017.
MEN ONLY
Do you usually get up to urinate during the night?
☐
Yes
☐
No
If yes, # of times enter text.
Do you feel pain or burning with urination?

☐
Yes
☐
No
Any blood in your urine?
☐
Yes
☐
No
Do you feel burning discharge from penis?
☐
Yes
☐
No
Has the force of your urination decreased?
☐
Yes
☐

No
Have you had any kidney, bladder, or prostate infections within
the last 12 months?
☐
Yes
☐
No
Do you have any problems emptying your bladder completely?
☐
Yes
☐
No
Any difficulty with erection or ejaculation?
☐
Yes
☐
No
Any testicle pain or swelling?
☐

Yes
☐
No
Date of last prostate and rectal exam? enter text.
review of systems
Check if you have, or have had, any symptoms in the following
areas to a significant degree and briefly explain.
☐
Skin/Hair/Nails enter text.
☐
Respiratory enter text.
☐
Neurologic enter text.
☐
Head/Neck enter text.
☐

Cardiovascular enter text.
☐
Recent changes in Weight enter text.
☐
Eyes Bilateral Myopia and Astigmstism
☐
Peripheral Vascular enter text.
☐
Recent changes in Energy level enter text.
☐
Ears enter text.
☐
Gastrointestinal enter text.
☐
Sleep/rest pattern enter text.
☐
Nose enter text.
☐

Urinary UTI
☐
Other pain/discomfort: enter text.
☐
Mouth/Throat enter text.
☐
Musculoskeletal enter text.
1
NR302 Health Assessment I
RUA: Health History Guidelines
NR302 Health History Guidelines V3.docx Revised:
04/2019
11
Purpose

Before any nursing plan of care or intervention can be
implemented or evaluated, the nurse assesses the individual
through the collection of both subjective and objective data.
The data collected are used to determine areas of need
or problems to be addressed by the nursing care plan. This
assignment will focus on collecting subjective assessment
data, synthesizing the data, and on identifying health/wellness
priorities based on the findings. The purpose of the
assignment is two-fold:
(physiological, psychosocial, cultural/spiritual, and
developmental) affecting health and wellness.
etween self and client
when conducting a health assessment.
Course Outcomes: This assignment enables the student to meet
the following course outcomes:
CO1. Explain expected client behaviors while differentiating
between normal findings, variations, and abnormalities.
(PO1)
CO2. Utilize prior knowledge of theories and principles of
nursing and related disciplines to integrate clinical
judgment in professional decision-making and implementation
of nursing process while obtaining a physical
assessment. (PO 4, 8)
CO3. Recognize the influence that developmental stages have
on physical, psychosocial, cultural, and spiritual
functioning. (PO 1)
CO4. Utilize effective communication when performing a health

assessment. (PO 3)
CO6. Identify teaching/learning needs from the health history of
an individual. (PO 2, 3)
CO7. Explore the professional responsibilities involved in
conducting a comprehensive health assessment and
providing appropriate documentation. (PO 6, 7)
Due date: Your faculty member will inform you when this
assignment is due. The Late Assignment Policy applies
to this assignment.
Total points possible: 100 points
Preparing the assignment
A Health History Worksheet that can be used to help you
organize the Family Medical History information you
will obtain from the Adult Participant is located in the
Resources section of the Expand page for Unit 2. The
use of this tool is optional. There are three parts to this
assignment.
1. Health History Assessment (50 points/50%)
Using the following components of a health history assessment
and your textbook for explicit details about
each category, complete a health assessment/history on an
individual of your choice. The person interviewed
must be 18 years of age or older and should NOT be a family
member or close friend. The purpose of this
restriction is to avoid any tendency to anticipate answers or to
influence how the questions are answered. Your
goal in choosing an interviewee is to simulate the interaction
between you and an individual for whom you
would provide care. It is important that you inform the person
of your assignment and assure him/her that the

information obtained will be kept confidential. Please be sure to
avoid the use of any identifiers in preparing
the assignment. Health History components to be included:
a) Demographics
b) Perception of Health
c) Past Medical History
d) Family Medical History
2
04/2019
21
e) Review of Systems
f) Developmental Considerations
g) Cultural Considerations
h) Psychosocial Considerations
i) Collaborative Resources
2. Reflection (40 points/40%)
Reflection is used to intentionally examine our thought
processes, actions, and behaviors in order to
evaluate outcomes. Provide a written reflection that describes
your experience with conducting this Health

History.
a) Reflect on your interaction with the interviewee holistically.
I. Consider the interaction in its entirety: include the
environment, your approach to the
individual, time of day, and other features relevant to
therapeutic communication and to the
interview process (if needed, refer to your text for a description
of therapeutic communication
and of the interview process).
b) How did your interaction compare to what you have learned?
c) What went well?
d) What barriers to communication did you experience?
I. How did you overcome them?
II. What will you do to overcome them in the future?
e) Were there unanticipated challenges to the interview?
f) Was there information you wished you had obtained?
g) How will you alter your approach next time?
3. Style and Organization (10 Points/10%)
Your writing should reflect your synthesis of ideas based on
prior knowledge, newly acquired information,
and appropriate writing skills. Scoring of your work in written
communication is based on proper use of
grammar, spelling and how clearly you express your thoughts
and reasoning in your writing.

• Grammar and mechanics are free of errors.
• Able to verbalize thoughts and reasoning clearly
• Use appropriate resources and ideas to support topic
For writing assistance (APA, formatting, or grammar) visit the
Citation and Writing Assistance: Writing Papers at CU
page in the online library.
https://library.chamberlain.edu/citations?_ga=2.240722054.4287
94323.1521654459-2019694983.1521654459
04/2019
31
Grading Rubric
Criteria are met when the student’s application of knowledge
within the paper demonstrates achievement of the outcomes for
this assignment.
Assignment Section and
Required Criteria
(Points possible/% of total points available)

Highest Level of
Performance
High Level of
Performance
Satisfactory
Level of
Performance
Unsatisfactory
Level of
Performance
Section not
present in
paper
Introduction of Disease
(50 points/50%)
50 points 46 points 41 points 25 points 0 points
Required criteria
1. Demographics
2. Perception of Health
3. Past Medical History
4. Family Medical History
5. Review of Systems
6. Developmental Considerations
7. Cultural Considerations
8. Psychosocial Considerations
9. Collaborative Resources

Includes no fewer
than 9
requirements for
section.
Includes no fewer
than 8
requirements for
section.
Includes no less
than 7
requirement for
section.
Present, yet
includes no
required criteria.
No requirements
for this section
presented.
Reflection
(40 points/40%)
40 points 36 points 33 points 20 points 0 points
Required criteria
1. Reflect on your interaction with the
interviewee holistically.
a) Consider the interaction in its entirety:
include the environment, your approach

to the individual, time of day, and other
features relevant to therapeutic
communication and to the interview
process (if needed, refer to your text for a
description of therapeutic communication
and of the interview process).
b) How did your interaction compare to
what you have learned?
Includes no fewer
than 7
requirements for
section.
Includes no fewer
than 6
requirements for
section.
Includes no fewer
than 5
requirements for
section.
Includes 4 or
fewer
requirements for
section.
No requirements
for this section
presented.

04/2019
41
Assignment Section and
Required Criteria
(Points possible/% of total points available)
Highest Level of
Performance
High Level of
Performance
Satisfactory
Level of
Performance
Unsatisfactory
Level of
Performance
Section not
present in
paper
c) What went well?

d) What barriers to communication did you
experience?
I. How did you overcome them?
II. What will you do to overcome them in
the future?
e) Were there unanticipated challenges to the
interview?
f) Was there information you wished you had
obtained?
g) How will you alter your approach next
time?
Style and Organization
(10 points/10%)
10 points 8 points 4 points 0 points
Required criteria
1. Grammar and mechanics are free of errors.
2. Able to verbalize thoughts and reasoning clearly
3. Use appropriate resources and ideas to support
topic
Includes no fewer than 3 requirements

for section.
Includes no fewer
than 2
requirements for
section.
Includes 1
requirements for
section.
No requirements
for this section
presented.
Total Points Possible = 100 points

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