Health History
Conduct a health history on a family member or friend. You can use the form located in your Health Assessment lab manual book or from Week Two classroom assignment. You do not need to submit the health history form with your paper. Be sure they give you permission. Using the interviewing techniques learned in Module 2, gather the following information. Use your textbook as your guide.
o Present Health
o Past Medical Health
o Family History
o Review of Systems
While this is only a partial health history, summarize in 3 -5 pages the information you gathered.
Include your answers to the following questions in the summary:
a. Was the person willing to share the information? If they were not, what did you do to encourage them?
b. Was there any part of the interview that was more challenging? If so, what part and how did you deal with it?
c. How comfortable were you taking a health history?
d. What interviewing techniques did you use? Were there any that were difficult and if so, how did you overcome the difficulty?
e. Now that you have taken a health history discuss how this information can assist the nurse in determining the health status of a client.
Sample Solution
Summary of Health History
Present Health
- Chief complaint: None
- Current medications: None
- Allergies: No known allergies
- Immunizations: Up to date
- Surgeries: None
- Accidents or injuries: None
- Tobacco use: Never smoked
- Alcohol use: Drinks socially on occasion
- Drug use: None
Full Answer Section
- Exercise: Exercises regularly
- Diet: Eats a healthy diet
- Sleep: Gets 7-8 hours of sleep per night
- Stress level: Manages stress well
- Childhood illnesses: Chickenpox, measles, mumps, rubella
- Adult illnesses: None
- Hospitalizations: None
- Surgeries: None
- Accidents or injuries: None
- Medications: None
- Allergies: No known allergies
- Immunizations: Up to date
- Father: Died of heart attack at age 65
- Mother: Alive and well
- Siblings: One brother, alive and well
- Children: None
- General: No complaints
- Skin, hair, and nails: No complaints
- Head, eyes, ears, nose, and throat: No complaints
- Cardiovascular: No complaints
- Respiratory: No complaints
- Gastrointestinal: No complaints
- Genitourinary: No complaints
- Musculoskeletal: No complaints
- Neurological: No complaints
- Hematologic: No complaints
- Endocrine: No complaints
- Psychiatric: No complaints
- Open-ended questions: Used to encourage the interviewee to share information.
- Closed-ended questions: Used to gather specific information.
- Active listening: Paying attention to what the interviewee is saying and asking clarifying questions.
- Reflection: Repeating back what the interviewee has said to ensure understanding.
- Summarization: Summarizing the key points of the interview.
- The interviewee was initially hesitant to share information about their family history. I encouraged them to share by explaining the importance of family history in understanding their own health risks.
- The interviewee became emotional when discussing a past illness. I gave them time to collect themselves and offered support.
- Identify potential health risks
- Develop a plan of care
- Provide education and counseling
- Evaluate the effectiveness of interventions