nur 2092 Health History Essay
Module
03 Written Assignment – Health History
Conduct a health history on a family member
or friend. Be sure they give you permission. Using the interviewing techniques
learned in Module 2, gather the following information. Use your textbook as
your guide.
Individual Health Assessment Form
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A response is required for EACH item in
EACH category.
Copy this document & record your responses in a text document (e.g.: Word or WordPerfect). That way you can just add the information without retyping the entire document. Please reformat and
delete things as appropriate.
Health History
Biographical data: (2 points)
Initals:____________
Age:
______________ Marital
status: ____M _____ S _____Sep. ____Cohab.
Birth date: _____________________ Number of dependents: ___________________
Educational level: ________________________ Gender: _____F _____ M _____Other
Occupation:
___________________________________¬¬¬¬_________________________
Ethnicity/nationality:
_____________________ Health insurance
____Yes _____No
Source of
history/reliability:________________________________________________
Present health history: (2 points)
Current medical conditions/chronic nur 2092 Health History Essay
illnesses:
Current medications:
Medication/food/environmental allergies:
Past health history: (8 points)
Childhood illnesses: Ask about mumps,
chickenpox, rubella, ear infections, throat infections, pertussis, and asthma.
Hospitalizations/Surgeries: Include reason
for hospitalization, year, and surgical procedures.
Accidents/injuries: Include head injuries
with loss of consciousness, fractures, motor vehicle accidents, burns, and
severe lacerations.
Major diseases or illnesses: Include heart
problems, cancer, seizures, and any significant adult illnesses.
Immunizations (dates of known):
Tetanus _______ Diphtheria ________ Pertussis ________ Mumps ________
Rubella _______ Polio _____________ Hepatitis B ______ Influenza _______
Varicella ______ Other
____________________________________________
Recent travel/military services: Include
travel within past year and recent and past military service.
Date of last examinations:
Physical examination _________ Vision ___________ Dental ___________
Family History (1 point)
Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any
major health issues, and, if indicated, cause and age of death (date of death,
if known). nur 2092 Health History Essay.
Now answer the questions below: (25 points)
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. nur 2092 Health History Essay.