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Choose/ select a patient to conduct an interview for a comprehensive health history. The patient may be a classmate, friend or family member.
Use the Health History Format to gather patient’s information. (Patient’s information will be secured, kept confidential, and only be viewed by instructor)
Your paper should:
be typed.
Use factual information.
be original work and will be checked for plagiarism.
have required APA format if references are utilized – type references according to the APA Style Guide.
Upload your file by clicking “Browse My Computer” for Attach File.
MIAMI DADE COLLEGE MEDICAL CAMPUS BENJAMÍN LEÓN SCHOOL OF NURSING
Instructions: Use the format below to conduct a comprehensive Health History interview.
I. Identifying Data/Source of the History and Reliability
1. Name
2. Address
3. Age
4. Date of Birth
5. Birthplace
6. Gender
7. Marital Status
8. Race
9. Ethnic Identity/Culture
10. Religion and Spirituality
11. Occupation
12. Health Insurance
13. Source of Referral
14. Source of Information and Reliability
II. Chief Complaint(s)
III. Present Illness
1. Reason for Seeking Care
2. Health Beliefs & Health Practices
3. Health Patterns (habits of smoking and alcohol)
4. Medications (prescriptions and over the counter)
5. Allergies
IV. Past Health History
1. Adult illnesses with dates for at least four categories: Medical, Surgical, Obstetrics/Gynecologic, and Psychiatric.
2. Hospitalizations
3. Outpatient Care
4. Childhood Illnesses
5. Mental and Emotional Health
6. Health Maintenance practices (immunizations, screening tests, lifestyles
issues, and home safety)
NUR 3069: ADVANCED HEALTH ASSESSMENT P a g e 1 | 3
V. Family History – outlines or diagram age and health, or age and cause of death, of siblings, parents, and grandparents. Please provide both narrative and genogram including:
a. Narrative history of immediate and extended family b. Genogram
VI. Personal and Social History
1. Occupational History
2. Educational level
3. Financial background
4. Roles and Relationships
5. Family origin and Culture
6. Social Structure and Emotional Concerns
7. Self-Concept and Self-Esteem
8. Functional assessment & Safety measures
9. Personal interests
VII. Nutritional Data and Health Promotion Activities
1. Provide a 24-hour diet recall of the patient
2. Types of health promotion activities that the patient currently practices
VIII. Developmental Data and Theories (see Module 1)
a. Select at least two theories (these could be nursing or other theories) to identify developmental aspects of your patient.
IX. Review of Systems – Narrative recording of presence or absence of common symptoms related to each major body system listed below stated by the patients/families:
1. Skin, Hair, and Nails
2. Head, Eyes, Ears, Nose, Throat (HEENT)
3. Neck
4. Breasts and Axillae
5. Respiratory
6. Cardiovascular
7. Peripheral vascular
8. Gastrointestinal
9. Musculoskeletal
10. Neurologic
11. Urinary
12. Male or Female Reproductive
NUR 3069: ADVANCED HEALTH ASSESSMENT
P a g e 2 | 3
X. Analysis of Findings: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________
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