HEAS 1000 Health History Form

HEAS 1000 Health History Form

Client’s Biographical Data
Initials:
Identified Gender:
Age:
Birthplace:
Marital Status:
Occupation:

Student Name(s):________________________________________________________________________

 

NorQuest Health History Form

 

Collection Date:   Collection Time:

 

 

 

 

 PLACE YOUR ORDER HERE

 

 

 

 

Health History Information List your questions in each section prior to the interview
Current Health Status (a short statement about present state of health; provide chronological record of current health problems): HEAS 1000 Health History Form
Past Health History (list childhood illnesses, accidents or injuries, chronic illnesses, mental health concerns, hospitalizations, operations, obstetrical history, immunizations, most recent examination dates for physical, dental, vision and hearing):
Past Family History (ages/health concerns, age at and cause of death of blood relatives – parents, grandparents, siblings): HEAS 1000 Health History Form
Allergies:
Prescribed Medications/Over-the-Counter:
Review of Systems List your questions in each section prior to the interview (if no concerns, check the No column; if concerns, check the Yes column and specify with details)
History of Concern	No	Yes	if Yes, specify concerns here
Respiratory System:
Cardiovascular System:
Gastrointestinal System:
Head, Eyes, Nose and Sinuses, Mouth and Throat, Neck:
Neurological System:
Urinary System:
Genital System:
Musculoskeletal System:
Peripheral Vascular System:
Integumentary System (Skin, Hair, Nails):
Hematological System:
Endocrine System:
Cultural and Social Considerations List your questions in each section prior to the interview
Cultural Health and Spiritual Practices. (List any spiritual traditions/practices that the client feels needs to be part of their care?):
Functional Assessment List your questions in each section prior to the interview
Activities of Daily Living (ADLs):
Instrumental Activities of Daily Living (IADLs):
Activity and Mobility:
Sleep and Rest:
Nutrition and Elimination:
Interpersonal Relationships and Resources:
Coping and Stress Management:
Smoking History, Alcohol and Substance Use:
Environmental Hazards:
Occupational Health:
Perception of Health
Describe the client’s perception of their health:
Indicate what the client feels are their two primary areas of health concern:

 

Please thank your client at the end of the interview for volunteering their time to help you develop    your data collection skills!

 

 

 

Areas of Health Promotion This section to be completed without your client present

Indicate here what you think are 3 areas of health concern relevant to assessment findings.  Recommend strategies and resources for each of the areas identified.

 

Practical Nurse
HEAS 1000, June 2019
HEAS 1000 Health History Assignment Rubric
Total: / 100
Criteria Category
3 2 1 0
Biographical Data All required data is
present.
Data contains
omissions or is absent.
Health History Information
Current Health Status Data is
comprehensive for
the system. Includes
all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include some
follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off
topic, limited or
not always
appropriate.
Data is inadequate
or absent. Questions
are inadequate,
inappropriate or
absent.
Past Health History Data is
comprehensive for
the system. Includes
all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include some
follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off
topic, limited or
not always
appropriate.
Data is inadequate
or absent. Questions
are inadequate,
inappropriate or
absent.
Family History Data is
comprehensive for
the system. Includes
all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include some
follow up on
abnormalities
identified.
Data is nonspecific or
incomplete.
Questions are
somewhat off
topic, limited or
not always
appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Allergies and Current
Medications
Data is
comprehensive for
the system. Includes
all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include some
follow up on
abnormalities
identified.
Data is nonspecific or
incomplete.
Questions are
somewhat off
topic, limited or
not always
appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Criteria Category
3 2 1 0
Review of Systems
Respiratory System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Cardiovascular System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Gastrointestinal System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
does not provide
rationale.
Head, Eyes, Nose and
Sinuses, Mouth and
Throat, Neck
Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Neurological System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Urinary System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Genital System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Musculoskeletal System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Peripheral Vascular
System
Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Integumentary System
(Skin, Hair, Nails)
Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Hematological System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Endocrine System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Criteria Category
2 1 0
Cultural and Social Considerations
Cultural Health and
Spiritual Practices
Data is comprehensive, astute
and insightful for the section.
Questions are relevant,
meaningful and appropriate for
the section.
Data is satisfactory and
contains basic information
for the section. Questions
are satisfactory and
appropriate for the section.
Data is inadequate or
absent. Questions are
inadequate, inappropriate or
absent.
Criteria Category
3 2 1 0
Functional Assessment
Activities of Daily Living
(ADLs)
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Instrumental Activities
of Daily Living (IADLs)
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Activity and Mobility Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Sleep and Rest Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Nutrition and
Elimination
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Interpersonal
Relationships and
Resources
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Coping and Stress
Management
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Smoking History,
Alcohol and Substance
Use
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Environmental Hazards Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Occupational Health Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Criteria Category
3 2 1 0
Perception of Health
Client’s Perception of
Health
Comprehensive and
concise data is
provided for the
section. Questions
are relevant,
meaningful and
appropriate for the
section.
Satisfactory and basic
data is provided for
the section.
Questions are
satisfactory and
appropriate for the
section.
Data is incomplete
or minimal for the
section. Questions
are somewhat off
topic, limited or
not always
appropriate.
Data is inadequate
or absent. Questions
are inadequate,
inappropriate or
absent.
Client’s Health Concerns Comprehensive and
concise data is
provided for the
section. Questions
are relevant,
meaningful and
appropriate for the
section.
Satisfactory and basic
data is provided for
the section.
Questions are
satisfactory and
appropriate for the
section.
Data is minimal
and limited for the
section. Questions
are off topic,
limited or not
always
appropriate.
Data is inadequate
or absent. Questions
are inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Areas of Health Promotion
Health Promotion
Identification
Identifies 3 areas of
health concern
relevant to
assessment findings.
Identifies 2 areas of
health concern
relevant to
assessment findings.
Identifies 1 area of
health concern
relevant to
assessment
findings.
Information is absent.
Health Promotion
Recommendations
Recommends
strategies to assess 3
areas of health
concern identified
with rationale.
Recommends
strategies to assess 2
areas of health
concern identified
with rationale.
Recommends
strategies to assess
1 areas of health
concern identified
with rationale.
Information is absent.
Health Promotion
Resource
Recommendations
Recommends 2 or
more resources to
address health
promotion needs.
Recommends 1
resources to
address health
promotion need.
Information is absent
Criteria Category
3 2 1 0
Writing Conventions and Appearance
Appearance Data/information is
typewritten, uses
consistent and clear
organizational
structure
throughout the
form. Workload
distribution is
indicated
throughout the
form (if applicable).
Data/information is
typewritten, uses
some consistent
organizational
structure throughout
most of the form.
Workload distribution
is indicated
throughout most the
form (if applicable).
Data/information
is typewritten,
but lacks
organizational
structure
throughout the
form. Workload
distribution is
indicated
throughout most of
the form (if
applicable).
Data/information is not
typewritten or lacks
clear and consistent
organizational
structure throughout
the form. Workload
distribution is not
included on the form (if
applicable).
Writing Conventions
(spelling, grammar,
punctuation,
capitalization)
Free of writing
convention errors.
Relatively free of
writing convention
errors.
There are a significant
amount of writing
convention errors.

 

 

HEAS 1000 Health History Assignment (20%)
This assignment is divided into three parts. You may choose to work with one partner, or work
individually. Please read through all of the instructions before you begin. HEAS 1000 Health History Form
Purpose:
To provide the student with an opportunity to practice performing a comprehensive health history on a
client. This will be done on an adult of the student’s own choosing. Areas of health concern will be
identified to determine health promotion needs in conjunction with the client.
You will be assessed on how you apply an understanding of the following general learning outcomes:
• conduct a health history interview of a client HEAS 1000 Health History Form
• validate and document the findings of the health history
• determine health promotion and disease prevention needs requiring client teaching
Instructions:
Part 1 – Interview Preparation:
1. Find a client, with a stable medical health condition, who is willing to participate in your health
history assignment and meets the criteria below:
a. an adult aged 16-64 (e.g., friend, family member or peer who is not your partner in this
assignment) or,
b. an older adult aged 65-up (e.g., friend, family member)
2. Provide the client with the following background information prior to setting up an interview. It
is important to communicate to the client the process and purpose of this interview:
a. no personal identifiers will be recorded on the form (only the client’s initials will be
recorded)
b. the interview process is private and client’s recorded information is confidential
c. the interview may take approximately one hour
d. the purpose of this assignment is to help me (the student) practice collecting health
history data from a client
e. if the client feels uncomfortable answering a question, indicate the reason why (if
provided), otherwise record the data as ‘client declined’ for that question
3. In consultation with your client, decide on a date, time and private location to conduct the
interview.
4. Use the Health History Form provided in Moodle for recording the data. Note: during the
interview you may be recording data in handwritten form.
5. Prior to the interview research and prepare appropriate questions for each section. Refer to the
Jarvis textbook for sample questions (textbook page numbers are listed in Part 2 of this
assignment).
Practical Nurse
HEAS 1000, June 2019 2
a. type all interview questions in each section of the form so that you are prepared and on
topic
b. the quality of your questions will be assessed as part of this assignment
6. If working with a partner, indicate on the Health History Form in each section which person is
asking the questions and which person is recording the information. Both partners are required
to lead the interview process by taking turns asking questions and you must distribute the
workload evenly, each person taking on 50% of the workload.
7. Make sure you and your partner (if applicable) have a printed copy of the form.
Part 2 – The Interview:
8. Record data in each section listed on the form. If the client indicates that there are ‘no issues’ in
a section, indicate that response beside the question. If the client was uncomfortable
responding to a section, indicate that response beside the question.
All of the following sections must contain questions and assessment data:
a. Biographical Data (only: initials, identified gender, age, birthplace, marital status,
occupation, collection date/time), p. 62-63 HEAS 1000 Health History Form
b. Health History Information, p. 63-65
c. Review of Systems, p. 65-68
d. Cultural and Social Considerations (related to health and health care), p. 65 & chapter 3
e. Functional Assessment, p. 68-70 (if you are choosing an older adult, refer also to chapter
31)
f. Perception of Health
9. Conduct the health history interview with your client
10. After collecting the health history data, ask the client the following questions and record it in the
Perception of Health section of the form:
a. to describe their perception of their health
b. to identify two primary areas of health concern and ask the client why these areas of
concern were identified
11. At the end of the interview, remember to thank your client for his/her participation in this
assignment.
Part 3 – Areas of Health Promotion:
12. After the interview has been completed, indicate what three areas you feel should be addressed
with health promotion materials/teaching recommendations for the client. (Note: your areas of
health promotion may not be the same as the client’s). Provide rationale why you choose the
three areas and identify health promotion strategies and resources for each area. Record this in
the Areas of Health Promotion section of the form.
Submission requirements:
All data collection on the Health History Form must be typewritten, well-organized and utilize proper
writing conventions (see rubric). Submit your assignment to the Health History Assignment dropbox in
Practical Nurse HEAS 1000 Health History Form
HEAS 1000, June 2019 3
Moodle. If you are working with a partner, only one person is required to submit the Health History
Form (HHF).
• Working with a partner: one person is required to submit the Health History Form to
the Moodle dropbox naming the file with the two last names of the partners.
Example of file name: HHF Smith_Williams.docx
• Working individually: submit the Health History Form with your last name Example of
file name: HHF Smith.docx
Assessment:
You will be assessed using the assignment rubric created as part of this assignment package. The rubric
is located as a PDF file in the assignment dropbox. Feedback about your assignment will be provided in
Moodle gradebook. HEAS 1000 Health History Form