If person says no document denies)

MILLIKIN UNIVERSITY
College of Professional Studies: School of Nursing
NU 311: Health Assessment
PART I: HEALTH HISTORY
I.

IDENTIFYING DATA

DATE_____________________

Initials ___________________
Age______________________
DOB ____________________
Gender ___________________
Race _____________________
Primary Language ____________________

Birthplace _______________________
Ethnic Origin ____________________
Marital Partner Status____________
Occupation (Usual or Present)
Religion________________________
Interpreter needed? Y N

II. SOURCE OF INFORMATION (include source and reliability)

- Who is giving you this information?
- How willing are they to communicate?
- Are the answers consistent (ask questions in multiple ways)?
- How reliable are they?
- Note any special circumstances, such as use of interpreter.
III. REASON FOR SEEKING CARE
- Put in persons own words describing reason for visit. PUT IN QUOTATIONS.
- Dont use medical terminology
- Ask for their signs and symptoms (itching, pain, nausea, etc.)
IV. PRESENT HEALTH or HISTORY OF PRESENT ILLNESS
General state of health OR chronological account, analysis of any symptoms. (include the
8 critical characteristics of any symptom) Also note significant negatives.
-

Location: Be specific; ask the person to locate precisely where the pain is. Is the pain
localized to this site or radiating? Is the pain superficial or deep?
Character/Quality: Use descriptive terms such as burning, sharp, dull, aching, gnawing,
throbbing, shooting, viselike. Use similes if you can.
Quantity/Severity: What is their pain scale? Is it mild, moderate, or severe?
Timing: How long did the symptom last? Was it steady or did it come and go during that
time? Did it resolve completely and reappear days or weeks later?
Setting: Where was the person/what was person doing when symptom started?
Aggravating or Relieving Factors: What makes the pain worse? Is it aggravated by
weather, activity, food, medication, standing bent over, fatigue, time of day, or season?
What relieves it? What is the effect of any treatment? What have you tried/What seems to
help?
Associated Factors: Is this primary symptom associated with any others? Review the
body system related to this symptom now rather than waiting for the Review of Systems
section later. Many clinicians review the persons medication regimen now because the
presenting symptom may be a side effect or toxic effect of a chemical.
Patients Perception: Find out the meaning of the symptom by asking how it affects daily
activities. How has this affected you? Is there anything you cant do now that you could
do before? What do you think it means?

V.
PAST HEALTH
Childhood illnesses, serious or chronic illness, accidents/injuries, operations, hospitalizations,
obstetric history, immunizations, allergies, current medications and last examination date.
-

VI.

Childhood Illnesses: Measles, mumps, rubella, chickenpox, pertussis, and strep throat?
Ask about serious illnesses that may have had aftereffects for the person in late years.
Accidents/Injuries: Auto accidents, fractures, penetrating wounds, head injuries
(especially if associated with unconsciousness), and burns.
Serious/Chronic Illnesses: Asthma, depression, diabetes, hypertension, heart disease,
HIV, hepatitis, sickle-cell anemia, cancer, and seizure disorders.
Hospitalizations: Cause, name of hospital, how the condition was treated, how long the
person was hospitalized, and name of the physician.
Operations: Type of surgery, date, name of the surgeon, name of the hospital, and how
the person recovered.
Obstetric History: Gravidity (number of pregnancies), Term (number of deliveries in
which the fetus reached full term), Preterm (number of preterm pregnancies),
Miscarriages or Abortions (number of incomplete pregnancies), Living (number of
children living).
Immunizations: Routinely assess vaccination history and urge the recommended
vaccines. Flu (annually), Td/Tdap (once and boost every 10 years), Varicella/HPV for
male and female (3 doses ages 9-26 years), Zoster (after 60 years), Measles-mumpsrubella (1 or 2 doses), Pneumococcal (once and boost after 65 years), Meningococcal and
Hepatitis A/B.
Last Examination Date: Physical, dental, vision, hearing, electrocardiogram, chest x-ray
film, mammogram, Pap test, stool occult blood, serum cholesterol.
Allergies: Note both the allergen (medication, food, or contact agent such as fabric or
environmental agent) and the reaction (rash, itching, runny nose, watery eyes, or more
serious difficulty breathing). With a drug this symptom should not be a side effect but a
true allergic reaction.
Current Medications: For all currently prescribed medications, note the name (generic or
trade), dose, and schedule How often do you take it each day? What is it for? How
long have you been taking it? Do you have any side effects? If not taking it, what is the
reason you stopped taking it? Ask about nonprescription/OTC drugs: aspirin, vitamins,
birth control, antacids, cold remedies, acetaminophen. For any pain reliever ask how
many milligrams the person takes. Ask about herbal medications.

FAMILY HISTORY
Note which relative(s) if positive
Heart disease ____________________
High blood pressure _______________
Stroke __________________________
Diabetes ________________________
Blood disorders __________________
Breast/ovarian cancer _____________
Cancer (other) ___________________
Sickle cell _______________________
Arthritis ________________________

Allergies ________________________
Asthma _________________________
Obesity _________________________
Alcoholism/drug addiction __________
Mental illness ____________________
Suicide __________________________
Seizure disorder ___________________
Kidney disease ___________________
Tuberculosis _____________________

Draw genogram noting siblings, parents, spouse, children, and grandparents. Note ages,
causes of any deaths, and presence of any illnesses or family-related conditions.

VII. REVIEW OF SYSTEMS (3Qs at least for each system, write Presence or Absence of all
symptoms. This section is limited to patient statements and subjective data.
-

General Overall Health State

Present weight (gain or loss, over what period of time, by diet or other factors), fatigue,
weakness or malaise (discomfort), fever, chills, sweats or night sweats.
Skin
History of skin disease (eczema, psoriasis, hives), pigment or color change, change in
mole(s), excessive dryness or moisture, pruritus (severe itching), excessive bruising, rash
or lesion.
Hair
Recent loss, change in texture. Nails: change in shape, color, or brittleness.
o Health Promotion: Amount of sun exposure; method of self-care for skin and
hair.
Head
Any unusually frequent or severe headache; any head injury, dizziness by fall in BP
(syncope), or vertigo (whirling/loss of balance).
Eyes
Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, double-vision
(diplopia), redness or swelling, watering or discharge, glaucoma or cataracts.
o Health Promotion: Wear glasses or contacts; last vision check or glaucoma test;
how coping with loss of vision if any.
Ears
Earaches, infections, discharge and its characteristics, tinnitus (ringing/buzzing) or
vertigo (whirling/loss of balance).
o Health Promotion: Hearing loss, hearing aid use, how loss affects daily life, any
exposure to environmental noise, and method of cleaning ears.
Nose/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.
Mouth/Throat
Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue,
trouble swallowing (dysphagia), hoarseness or voice change, tonsillectomy, altered taste.
o Health Promotion: Pattern of daily dental care, use of dentures, bridge, and last
dental checkup.
Neck
Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter (swelling
of lymph node)
Breast
Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts.

Health Promotion: Performs breast self-exam, including its frequency and

method used; last mammogram.

Axilla
Tenderness, lump or swelling, rash.
Respiratory
History of lung diseases (asthma, emphysema, bronchitis, pneumonia, TB), chest pain
with breathing, wheezing or noisy breathing, shortness of breath, how much activity
produces shortness of breath, cough, sputum (color, amount), hemoptysis (coughing up
blood), toxin or pollution exposure.
o Health Promotion: Last chest X-Ray study, TB skin test.
Cardiovascular
Chest pain, pressure, tightness or fullness, palpitation, cyanosis (bluish tint of skin),
dyspnea on exertion (specify amount of exertion [e.g., walking one flight of stairs,
walking from chair to bath, or just talking]), orthopnea (shortness of breath when lying
down), paroxysmal nocturnal dyspnea (attacks of severe shortness of breath and
coughing that generally occur at night), nocturia (need to wake up in the middle of the
night and urinate), edema (swelling), history of heart murmur, hypertension, coronary
heart disease, anemia.
o Health Promotion: Date of last ECG or other heart tests, cholesterol screening.
Peripheral Vascular
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 (cramping),
thrombophlebitis (inflammation of the walls of the veins associated with thrombosis),
ulcers.
o Health Promotion: Does the work involve long-term sitting or standing? Avoid
crossing legs at the knees. Wear support hose?
Gastrointestinal
Appetite, food intolerance, dysphagia, 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 (liver or gallbladder, ulcer, jaundice, appendicitis, colitis), flatulence, frequency
of bowel movement, any recent change, stool characteristics, constipation or diarrhea,
black stools, rectal bleeding, rectal conditions (hemorrhoids, fistula).
o Health Promotion: Use of antacids or laxatives. (Alternatively, diet history and
substance habits can be placed here.)
Urinary
Frequency, urgency, nocturia, (number of times the person awakens at night to urinate,
recent change); dysuria; polyuria (a lot) or oliguria (small amount); 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.
o Health Promotion: Measures to avoid or treat urinary tract infections, use of
Kegel exercises after childbirth.

Male/Female Genital System

Male: Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia.
o Health Promotion: Perform testicular self-exam? How frequently?
Female: Menstrual history (first period, last period, cycle and duration, any amenorrhea
(absence of menstruation) or menorrhagia (heavy bleeding during menstruation),
premenstrual pain or dysmenorrhea (painful menstruation/cramps), intermenstrual
spotting), vaginal itching, discharge and its characteristics, age at menopause,
menopausal signs or symptoms, postmenopausal bleeding.
o Health Promotion: Last gynecologic checkup and last Pap test.
Sexual Health
Start off with I usually ask all patients about their sexual health. Then ask: Are you
presently in a relationship involving intercourse? Are the aspects of sex satisfactory to
you and your partner? Are condoms used routinely? Is there any dyspareunia or
difficult/painful sex (for female) or are there any changes in erection or ejaculation (for
male)? Are there contraceptives used? Is the contraceptive method satisfactory? Are you
aware of contact with a partner who has any STI?
Musculoskeletal
Is there are history of arthritis or gout? In the joints: pain stiffness, swelling (location,
migratory nature), deformity, limitation of motion, noise with joint motion? In the
muscles: any muscle 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?
o Health Promotion: How much walking per day? What is the effect of limited
range of motion on ADLs such as grooming, feeding, toileting, dressing? Are any
mobility aids used?
Neurologic
History of seizure disorder, stroke, fainting, blackouts. Motor function: Weakness, tic or
tremor, paralysis, or coordination problems? Sensory function: numbness, tingling
(paresthesia)? Cognitive function: memory disorder (recent or distant, disorientation)?
Mental status: any nervousness, mood change, depression, or history of mental health
dysfunction or hallucinations?
o Health Promotion: Alternatively, data about interpersonal relationships and
coping patterns are placed here.
Hematologic
Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node
swelling, exposure to toxic agents or radiation, blood transfusion and reactions.
Endocrine
History of diabetes or diabetic symptoms (polyuria/excessive urination,
polydipsia/thirsty, polyphagia/increased appetite), history of thyroid disease, intolerance
to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship
between appetite and weight, abnormal hair distribution, nervousness, tremors, and need
for hormone therapy.

VIII. FUNCTIONAL ASSESSMENT

(includes ADLs)
-

Self-Esteem/Self-Concept
Education (last grade completed, other significant training), financial status (income
adequate for lifestyle and/or health concerns), value-belief system (religious practices and
perception of personal strengths).
Activity/Exercise
Tell me how you spend a typical day., Note ability to perform ADLs: independent or
needs assistance with feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer,
walking standing, or climbing stairs. Is there any use of wheelchair, prostheses, or
mobility aids?
Record leisure activities enjoyed and the exercise pattern (type, amount per day or week,
method of warm-up session, method of monitoring the response of the body to exercise).
Sleep/Rest
Sleep patterns, daytime naps, any sleep aids used.
Nutrition/Elimination
Record the diet by a recall of all food and beverages taken over the past 24 hours (see
Chp. 11 for suggested method of inquiry). Is that menu typical of most days? Describe
eating habits and current appetite. Who buys food and prepares food? Are your finances
adequate for food? Who is present at mealtimes? Indicate any food allergy or
intolerance. Record daily intake of caffeine. Ask about usual pattern of bowel elimination
and urinating, including problems with mobility or transfer in toileting, continence, use of
laxatives.
Interpersonal Relationships/Resources
How would you describe your role in the family? How would you say you get along
with family, friends, and co-workers? Ask about support systems composed of family
and significant others: To whom could you go for support with a problem at work, your
health, or a personal problem?. Include contact with spouse, siblings, parents, children,
friends, organizations, workplace. Is time spent alone pleasurable and relaxing, or is it
isolating?
Spiritual Resources
Faith: Does religious faith or spirituality play an important part in your life? Do you
consider yourself to be a religious or spiritual person?
Influence: How does your religious faith or spirituality influence the way you think
about your health or care for yourself?
Community: Are you a part of any religious or spiritual community or congregation?
Address: Would you like me to address any religious or spiritual issues or concerns with
you?
Coping and Stress Management

Types of stresses in life, especially in the past year; any change in lifestyle or any current
stress; methods tried to relieve stress and whether these have been helpful.
Personal Habits (caffeine, alcohol, illicit/street drugs/prescription abuse)
Do you smoke cigarettes (pipe, use chewing tobacco)? At what age did you start? How
many packs do you smoke per day? How many years have you smoked?
o Record the number of packs smoked per day (PPD) and duration. Then ask,
Have you ever tried to quit? and How did it go? to introduce plans about
smoke cessation.
Ask if person drinks alcohol. When was the last drink? How much did you drink that
time? In the past 30 days, how many days would you say that you drank alcohol? Has
anyone ever said that you had a drinking problem?
o Cut down, Annoyed, Guilty, and Eye-opener (CAGE) test.
If person answers yes to two or more, you should suspect alcohol abuse
and continue with more substance-abuse assessments. If person answers
no, ask the reason for this decision. Any history of alcohol treatment?
Involved in recovery activities? History of a family member with
problem drinking?
Ask specifically about prescription painkillers or other illicit/street drugs. Indicate
frequency of use and how use has affected work or family.
Environment/Hazards
Housing and neighborhood, safety of area, adequate heat/utilities, access to
transportation, and involvement in community services. Note environmental health,
including hazards in workplace, hazards at home, use of seatbelts, geographic or
occupational exposures, and travel or residence in other countries, including time spent
abroad during military service.
Intimate Partner Violence
How are things at home? Do you feel safe? Have you ever been emotionally or physically
abused by your partner or someone important to you? Within the past year, have you been
hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or
ex-partner? If yes, ask: by whom? How many times? Does your partner ever force you
into having sex? Are you afraid of your partner or ex-partner?
Occupational Health
Ask person to describe his/her job. Ever worked with any health hazards while at work?
Wear any protective equipment? Any work programs in place that monitor exposure?
Aware of any health problems now that may be related to work exposure? Note the
timing of the reason for seeking care and whether it may be related to change in
work/home activities, job titles, or exposure history. Ask the person what he or she likes
or dislikes about the job.

X. PERCEPTION OF HEALTH
- How do you define health? How do you view your situation now? What are your
concerns? What do you think will happen in the future? What are your health goals?
What do you expect from us as nurses, physicians (or other health care providers)?

NU 311/Spring 2016/Health History