NR302 Health Assessment I
Use this worksheet during your interview, and transcribe the results to the complete the Health History
Assessment, the student will interview a client of their choice over 18 years of age
Doing one of the following may get you a ZERO in the gradebook and an Academic Integrity Hearing
The patient is:
- Not yourself
- Not a close family member
- Not the same person for both 302 & 304
- Not the person from the last time you took this course
- Not your RUA from a previous course
If you copy this to your RUA, then you will likely have no shortage of formatting issues
1. Biographical Data
Initials: PZ Gender: F Age: 24 Primary Language:
Present City and state: Chicago, IL Birthdate: 11/23/1995
Birthplace: Chicago Ethnicity: White Religion: Catholic
Relationship Status (Single/Married/Divorced, etc): Married
Children: 0, Gender(s) - , Age(s) -
Last grade completed in school: 16
Occupation/Occupational History: Nurse
Does your patient have health insurance (Yes/No):
If yes is it Private? Medicare? Medicaid?: Private
2. Source (who is providing the information): The Patient
Reliability (is the source reliable/consistent with answers)? (Yes/No):
3. Reason for Seeking Care: To assist student with a Health History Assignment.
4. Past Health:
Describe general health (in client’s own words):
Childhood illnesses: Measles, Mumps, Rubella, Chickenpox, Pertussis, Strep Throat,
…Rheumatic Fever, Scarlet Fever, Poliomyelitis, Patient denies any childhood illnesses
Accidents or injuries (include date):N/A
Serious or chronic illnesses: Alcohol/Drug Addiction, Anemia, Allergies, Arthritis/gout, Liver disease,
Asthma/lung disease, Blood disorders, Cancer, Heart Disease, Diabetes, Glaucoma or Cataracts,
Hypertension, Kidney Disease, Obesity, Respiratory disease, Stroke, Mental Illness/depressio, Other
(specify)
Hospitalizations (reason and date): N/A
Surgeries (name procedure, date): N/A
Immunizations RECIEVED: Flu (Influenza), Td/Tdap (Tetanus-diphtheria-pertussis) , Shingles (Zoster),
Pneumonia (Pneumococcal), Chickenpox (Varicella), Patient denies ever receiving immunizations
Last physical examination date: 05/2019
Allergies (Medications, foods, latex, environmental - Including reactions): none
Current medications (Prescribed and over the counter):
Name of medication(s) and why the client taking it:
5. Family History – Specify Which Relative(s):
◻ Alcohol/Drug Addiction ◻ Anemia
◻ Allergies ◻ Arthritis/gout
NR302 Health Assessment I
◻ Asthma/lung disease ◻ Blood disorders
◻ Cancer ◻ Diabetes
◻ Glaucoma or Cataracts ◻ Heart Disease
◻ Hypertension ◻ Kidney Disease
◻ Obesity ◻ Respiratory disease
◻ Stroke ◻ Mental Illness/depression
◻ Liver disease ◻ Other (specify)
6. Review of Systems (ROS)
Remember, this is not a physical assessment! You are asking questions regarding each system for
signs and symptoms. Ask your client about every body system. Please refer to a medical
dictionary to learn the meaning of terms that you may not know.
General Overall Health State:
Stated Height: 5’11’’
Stated Weight: 145
Calculated BMI: 20.2
GENERAL HEALTH STATE: Does patient use hearing aids? Y/N Legs – coldness,
Yes No How patient clean the ears? numbness or tingling
Y/N Weight gain/loss NOSE AND SINUSES: Y/N Swelling of legs
_____ Over what period? Y/N Discharge Y/N Discoloration hands/feet
Y/N Frequent/severe colds GASTROINTENTESTINAL
Y/N Fatigue Y/N Sinus pain SYSTEM:
Y/N Weakness or malaise Y/N Nosebleeds Y/N Poor appetite
Y/N Fever/Chills Y/N Change in sense of smell Y/N Food intolerance
Y/N Night Sweats MOUTH AND THROAT: Y/N Dysphagia
SKIN: Y/N Mouth pain Y/N Heartburn, indigestion,
Y/N Pigment or color change Y/N Frequent sore throat pain
Y/N Change in mole Y/N Bleeding gums Y/N Nausea or vomiting
Y/N Excessive Y/N Toothache Y/N Change in stool
dryness/moisture Y/N Lesion in mouth/tongue characteristics
Y/N Bruising Y/N Altered taste Y/N Constipation
Y/N Rash or lesion Health Promotion: Y/N Diarrhea
HAIR: Date of last dental exam Health Promotion:
Y/N Recent loss 09/2019 Y/N Colonoscopy screening
Y/N Change in texture Y/N Does the client use Date of last screening-
NAILS: dental floss? URINARY SYSTEM:
Y/N Change in shape NECK: Y/N Frequency/urgency
Y/N Change in color Y/N Pain Y/N Nocturia
Y/N Brittleness Y/N Limitation of motion Y/N Incontinence
Health Promotion: Y/N Lumps or swelling Y/N Dysuria
Amount of sun exposure, Y/N Enlarged or tender nodes MALE GENITAL SYSTEM:
method of self-care for skin and BREAST: Y/N Penis or testicular
hair: Y/N Pain or lump pain/lumps
Uses sunscreen while exposed Y/N Nipple discharge Y/N Sores or lesions
to sun. Y/N Rash Health Promotion:
HEAD: Health Promotion: Y/N Does the client perform
Y/N Frequent or severe Y/N Does the client perform testicular self-examination?
headache breast self-examination? FEMALE GENITAL SYSTEM:
Y/N Head injury Date of last mammogram- Last menstrual
Y/N Dizziness (syncope) RESPIRATORY SYSTEM: period:01/20/2020
Y/N Vertigo Y/N Chest pain w/breathing Cycle and duration: 4-5 days
EYES: Y/N Wheezing/noisy Age at time of menopause:-
Y/N Difficulty with vision breathing Health Promotion:
(decreased acuity, blurring, Y/N Shortness of breath Date of last Pap test03/2020
blind spots). Y/N Cough SEXUAL HEALTH:
Y/N Eye pain Y/N Toxin or pollution Y/N Currently sexually active
Y/N Diplopia (double vision) exposure Y/N Use of contraception
Y/N Redness or swelling Health Promotion: Y/N Sexually transmitted
Y/N Watering or discharge Date of last chest x-ray- infection
CARDIOVASCULAR MUSCULOSKELETAL
SYSTEM: SYSTEM:
Y/N Chest pain Y/N Pain/stiffness/swelling in
Health Promotion: Y/N Palpitations joints
When was last vision exam and Y/N Cyanosis Y/N Limited range of motion
does the patient wear glasses? Y/N Dyspnea on exertion in joints
EARS: Y/N Edema Y/N Pain/cramps/weakness in
Y/N Earaches Health Promotion: muscles
Y/N Infections Date of last EKG- Y/N Gait problems
Y/N Discharge PERIPHERAL VASCULAR Y/N Back pain or stiffness
Y/N Tinnitus/vertigo SYSTEM: NEUROLOGIC SYSTEM:
Health Promotion: Y/N Weakness, tic or tremor
Y/N Numbness or tingling Y/N Lymph node swelling Y/N Changes in skin
(extremities) Y/N Exposure to toxic pigmentation
Y/N Memory disorder agents/radiation Y/N Excessive sweating
Y/N Mood change Y/N Blood Y/N Relationship –
HEMATOLOGIC SYSTEM: transfusion/reaction appetite/weight
Y/N Bleeding (skin, mucous ENDOCRINE SYSTEM: Y/N Abnormal hair distribution
membranes) Y/N Intolerance heat or cold Y/N Nervousness/tremors
Y/N Excessive bruising
FUNCTIONAL ASSESSMENT (INCLUDING ACTIVITIES OF DAILY LIVING)
Activity and Exercise:
Daily profile, usual pattern of a typical day Work, dinner, shopping, rest, bed.
Is the client independent with ADL's? Y/N
If no, what ADL’s does the client require assistance with?
Sleep and Rest:
How many hours does the client sleep per night? 7-9 hours
Nutrition and Elimination:
Record a 24-hour diet recall – List everything the client has had to eat or drink for the past 24 hour’s Coffee,
apple, chicken soup, salad, hamburger.
Is this menu pattern typical of most days (Y/N)?
Patterns of elimination or difficulty with urination or bowel movements:
Personal Habits:
Daily intake caffeine (coffee, tea, colas) – how much does the client consume in a 24 hour period2 cups coffee
Does the client smoke or have they ever smoked cigarettes, used smokeless tobacco, or e-cigarettes? Yes /
No
Age started: Daily use for how many years:
Packs per day: Have you ever tried to quit. If so, how did it go?
Does the client consumer alcohol? Yes/No
If yes: Date of last alcohol use:
Out of the last 30 days on how many days did the client consume alcohol?
Does the client currently or have they ever used any street drugs? Yes/No
If yes, specify (marijuana, cocaine, heroin, amphetamines, barbiturates, pain meds, etc.)
If yes: Last use of street drugs: Frequency of use:
Environmental Hazards:
Does the client live in a safe neighborhood? Y/N
Does the client feel safe in their own home? Y/N
Does the client have adequate heat and other utilities in the home? Y/N
Does the client have access to transportation? Y/N
Occupational Health:
Does the client currently experience or have they ever experienced health hazards in their place of
employment (e.g., asbestos, inhalants, chemicals, repetitive motion)?No
Cultural Considerations: “Goes to church with family”
(This includes but is not limited to religion, culture, beliefs, and ethnic customs that can influence how clients
understand health concepts, how they take care of their health, and how they make health decisions.)
Developmental and Psychosocial Considerations: Erikson’s Theory of Psychosocial Development level:
Collaborative Resources Utilized or available to the client: Dial-a-ride, community center, etc
