LONG ISLAND UNIVERSITY
HARRIET ROTHKOPF HEILBRUNN SCHOOL OF NURSING
BROOKLYN, NEW YORK
NUR 220L HEALTH ASSESSMENT AND HEALTH PROMOTION LAB
Comprehensive Health History II*
*To be completed as Homework and submitted in Lab. Student will perform a Comprehensive Health History on an adult/older adult who has a medical condition and taking prescribed medications.
Student Name: ___________________________________ Date: ________________
Biographical Data
Client’s Initials ________ Gender________ DOB________ Age________ Race_________________
Marital Status________ Nationality ________ Culture ________ Primary Language ________________
Religion ______________ Occupation____________________ Education________________________
Sexuality _____________ Height___________ Weight____________ BMI _________________
Source of Data________________________________ Reliability of Source ______________________________
Contact Person (Include relationship) _______________________________________________________________
Reason for Seeking Healthcare / Chief Complaint: ______________________________________________
_________________________________________________________________________________________
Current Health Status or History of Present Illness (For HPI use PQRST; For Pain use COLDSPA)
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Current Medications (Dose, frequency, and reason): _________________________________________________________
_______________________________________________________________________________________
Current Medical Diagnoses (Include dates of diagnosis): ______________________________________________________
_______________________________________________________________________________________
Medication/Food/Environmental Allergies (Describe reaction that occurs if allergies exist): _______________________
_______________________________________________________________________________________
Past Medical History
Childhood Illnesses: (Check all that apply)
Measles ______ Mumps ______ Rubella ______ Chicken Pox______
Pertussis ______ Influenza ______ Ear Infections ______ Other ___________________
Previous Medical Conditions, Hospitalizations, Surgeries: __________________________________ _________________________________________________________________________________
Accidents/Injuries: _________________________________________________________________ _________________________________________________________________________________
Travel Outside USA: _______________________________________________________________ _________________________________________________________________________________
Immunizations: (Check all that apply)
Tetanus______ Rubella______ Pertussis______ Mumps______ Measles _______ Polio______
Hepatitis B______ Varicella______ Flu ______ Pneumonia ______ Other (Specify): _______________
Date of Last Examinations:
Physical Examination_________ Vision_________ Hearing _________ Dental____________
Female: PAP Smear____________ Mammogram________ Breast _________
LMP___________ Gravida_____ Para_____ Abortions_____ Miscarriage_________
Male: Prostate Exam____________ Testicular Exam ______________
Family History
- Document findings below and create genogram on the next page. Refer to page 53 in text.
- Include age and health issues. If deceased, indicate age and cause of death.
Mother and Father: ________________________________________________________________________ ________________________________________________________________________________________
Maternal Grandparents: ____________________________________________________________________ ________________________________________________________________________________________
Fraternal Grandparents: ____________________________________________________________________ ________________________________________________________________________________________
Parent’s Siblings: _________________________________________________________________________ ________________________________________________________________________________________
Client’s Siblings: _________________________________________________________________________ ________________________________________________________________________________________
Spouse/Significant Other/Partner: ____________________________________________________________
________________________________________________________________________________________
Children: ________________________________________________________________________________ ________________________________________________________________________________________
Personal and Psychosocial History
Family and Social Relations: ___________________________________________________________
Diet/Nutrition: ______________________________________________________________________
Activity/Exercise: ___________________________________________________________________
Sleep/Rest: ________________________________________________________________________
Oral Hygiene: ______________________________________________________________________
Hobbies: __________________________________________________________________________
Functional Ability (Check all that apply)
___Dressing ___Toileting ___Bathing ___Eating ___Ambulating ___Shopping ___Cooking ___Housekeeping
Personal Habits
Tobacco (show pack-year calculation)___________ Alcohol _______ Recreational Drugs_______
Health Practices (Frequency)
Physicals Exams _________ Dental Exams _________ Eye Exams ______________
Human Violence _________________________________________________________________
Review of Body Systems (Refer to pages 54 –65 in text for sample questions.)
General Health: ___________________________________________________________________
________________________________________________________________________________
Skin, Hair, Nails: __________________________________________________________________
________________________________________________________________________________
Head and Neck: ___________________________________________________________________
________________________________________________________________________________
Eyes and Ears: ____________________________________________________________________
________________________________________________________________________________
Nose, Mouth, Throat, Sinuses: _______________________________________________________
________________________________________________________________________________
Breast and Regional Lymphatics: _____________________________________________________
________________________________________________________________________________
Respiratory: _____________________________________________________________________
________________________________________________________________________________
Cardiovascular: __________________________________________________________________
________________________________________________________________________________
Peripheral Vascular: ______________________________________________________________
________________________________________________________________________________
Abdominal/Gastrointestinal: ________________________________________________________
________________________________________________________________________________
Genito-Urinary/Sexual Health: _______________________________________________________
________________________________________________________________________________
Musculoskeletal: __________________________________________________________________
________________________________________________________________________________
Neurologic: ______________________________________________________________________
________________________________________________________________________________
Hematologic: _____________________________________________________________________
________________________________________________________________________________
Endocrine: _______________________________________________________________________
________________________________________________________________________________
Social Determinants of Health
To what extent, if any, have the social determinants of health influenced the client’s current health, wellness, and/or illness state?
Age ________________________________________________________________________________
Gender _____________________________________________________________________________
Culture/Ethnicity _____________________________________________________________________
Education ___________________________________________________________________________
Physical Environment ____________________________________________________________________________________
____________________________________________________________________________________
Access to Health Care and Social Services ____________________________________________________________________________________
____________________________________________________________________________________
Risk Exposure _______________________________________________________________________
Socioeconomic Status (Income/Employment/Insurance) ____________________________________________________________________________________
____________________________________________________________________________________
Housing ____________________________________________________________________________
Employment and Working Conditions ____________________________________________________
___________________________________________________________________________________
Social Connectedness __________________________________________________________________
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