Health History Form
Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 200 points, with 10 points awarded for clarity of writing, which means the use of proper grammar, spelling, and medical language.
Type your answers on this form. Click Save as and save the file with the assignment name and your last name, for example, NR305_Milestone1_Form_Smith. When you are finished, submit the form to the Milestone #1 Dropbox by the deadline indicated in your guidelines. Post questions in the Q & A Forum or contact your instructor if you have questions about this assignment.
Disclaimer: The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do not need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.” If the client fails to disclose answers to several items, you will need to find another client who is willing to share.
| BIOGRAPHICAL DATA (10 points) | |
| Date: | |
| Initials: | |
| Age: | |
| Date of birth: | |
| Birthplace: | |
| Gender: | |
| Marital status: | |
| Race: | |
| Religion: | |
| Occupation: | |
| Health insurance: | |
| Source of information: | |
| Reliability of source of information: | |
| PRESENT HEALTH HISTORY/ILLNESS (20 points) | |
| Reason for seeking care: | |
| Health patterns: | |
| Health goals: | |
| HEALTH BELIEFS AND PRACTICES (15 points) | |
| Beliefs and practices: | |
| Factors influencing healthcare decisions: | |
| Related traits, habits or acts: | |
| MEDICATIONS (20 points) (Please refer to your assignment guidelines.) | |
| Prescription medications: | |
| Over-the-counter medications: | |
| Herbals: | |
| PAST HISTORY (20 points) | |
| Childhood diseases: | |
| Immunizations: | |
| Allergies: | |
| Blood transfusions: | |
| Major illnesses: | |
| Injuries: | |
| Hospitalizations: | |
| Labor and deliveries: | |
| Surgeries: | |
| Use of alcohol: | |
| Use of tobacco: | |
| Use of illicit drugs: | |
| EMOTIONAL HISTORY (15 points) | |
| Mental, emotional or psychiatric problems: | |
| FAMILY HISTORY (20 points) | |
| Father: | |
| Mother: | |
| Siblings: | |
| Grandparents: | |
| PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 points) | |
| Occupational history: | |
| Educational level: | |
| Financial background: | |
| ROLES AND RELATIONSHIPS (15 points) | |
| Significant others: | |
| Support systems: | |
| ETHNICITY AND CULTURE (10 points) | |
| Ethnicity and culture: | |
| Physical and social characteristics that influence healthcare decisions: | |
| SPIRITUALITY (5 points) | |
| Religious and spiritual needs: | |
| SELF-CONCEPT (5 points) | |
| View of self-worth: | |
| Future plans: | |
| REVIEW OF SYSTEMS (20 points) (Please refer to your assignment guidelines and Chapter 4 of your text. This is not a physical examination.) | |
| Skin, hair, nails: | |
| Head, neck, related lymphatics: | |
| Eyes: | |
| Ears, nose, mouth, and throat: | |
| Respiratory: | |
| Breasts and axillae: | |
| Cardiovascular: | |
| Peripheral vascular: | |
| Abdomen: | |
| Urinary: | |
| Reproductive: | |
| Musculoskeletal: | |
| Neurologic: |
Course Project Milestone 1: Health History
Guidelines and Grading Rubric
Purpose
The student will obtain a health history on a willing, nonrelated, adult participant in order to generate written documentation that is clear and accurate.
Course Outcomes
This assignment enables the student to meet the following Course Outcomes.
CO #3: Utilize effective communication when performing a health assessment. (PO #3)
CO #4: Identify teaching/learning needs from the health history of an individual. (PO #2)
CO #5: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO #6)
Points
This assignment is worth a total of 200 points.
Due Date
The Course Project Milestone 1: Health History assignment is to be submitted to the Dropbox by Sunday, 11:59 p.m. MT at the end of Week 4. The guidelines and grading rubric may be found in Doc Sharing. Post questions to the Q & A Forum. Contact your instructor if you need additional assistance.
Disclaimer
The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do not need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.” If the client fails to disclose answers to several items, you will need to find another client who is willing to share.
Directions
- Find an adult who is not related to you who is willing to let you take a health history.
- Download the NR305_Milestone1_Form from Doc Sharing. You will type your answers directly into this Word document. Your paper does not need to follow APA formatting; however, you are expected to be clear in your communication by using correct medical terminology, grammar, and spelling.
- Review the examples in Chapter 4 of your textbook to gain insight into how to document the health history. Remember this is a health history, not a physical examination. Avoid words like frequently, improved, increased, decreased, good, poor, normal, or WNL as they may have different meanings for different people. Instead, document the specific data that led you to these conclusions, for example, 3x/day instead of frequently, or consuming four servings of vegetables/day instead of increased vegetable servings.
- Save the file by clicking Save as and adding your last name to the file name, for example, NR305_Milestone1_Form_Smith.
- Submit the completed form to the Dropbox by Sunday, 11:59 p.m. MT at the end of Week 4.
- Please post questions in the weekly Q & A Forums so the entire class may view the answers.
Grading Criteria
| Category | Points | % | Description |
| Biographical Data | 10 | 5 | Date of health history, client’s initials, age, date of birth, birthplace, gender, marital status, race, religion, occupation, health insurance information, source of information, and the reliability of the source. Do not include identifying information such as phone numbers, address, and so on. |
| Present Health History/ Illness | 20 | 10 | Reasons for seeking care, health patterns, and health goals. |
| Health Beliefs and Practices | 15 | 8 | Health beliefs and practices including factors that influence their healthcare decisions, related traits, habits, or acts that affect a client’s health. |
| Medications | 20 | 10 | Use of prescription medications, over-the-counter medications, and/or any herbals. Include name, dose, purpose, duration, frequency, and desired or undesired effects of each of the medications. |
| Past History | 20 | 10 | Childhood diseases, immunizations, allergies, blood transfusions, major illnesses, injuries, hospitalizations, labor and deliveries, surgeries, and use of alcohol, tobacco and illicit drugs. |
| Emotional History | 15 | 8 | Includes information about any mental, emotional, or psychiatric health problems. |
| Family History | 20 | 10 | Review of health history of the father, mother, sibling(s), and grandparents to determine if any genetic or familial patterns of health or illness might affect current health status. |
| Psychosocial/ Occupational History | 15 | 8 | Includes information about occupational history, educational level, and financial background. |
| Roles and Relationships | 15 | 8 | Information about the client’s roles and relationships; including identifying a significant other and support systems (friends, neighbors, club members, clergy, church members, and members of the healthcare team). |
| Ethnicity and Culture | 10 | 5 | Client’s ethnicity and culture, and physical and social characteristics that influence healthcare decisions. |
| Spirituality | 5 | 2 | Client’s religious and spiritual needs. (Spirituality refers to the individual’s sense of self in relation to others and a higher being.) |
| Self-Concept | 5 | 2 | Includes information on how they view their self-worth and plans for the future. |
| Review of Systems
(This is NOT a physical examination) |
20 | 10 | Focus is to uncover current and past information about each body system and its organs. Ask about the system function and any abnormal signs or symptoms, paying attention to gathering information about the functional patterns of each system. |
| Clarity of Writing | 10 | 5 | Content is organized logically and clearly understandable. Documentation is clear and accurate. Words like frequently, improved, increased, and decreased not used, instead provide specific examples. |
| Total | 200 points | 100% | A quality paper will meet or exceed all of the above requirements. |
Grading Rubric
Assignment Criteria
A
Outstanding or highest level of performance
B
Very good or high level of performance
C
Competent or satisfactory level of performance
F
Poor or failing or unsatisfactory level of performance
Biographical Data
(10 points)
All required criteria included. No errors.
(10 points)
No more than one required element missing.
(8–9 points)
More than two required elements missing.
(6–7 points)
Three or more required elements missing.
(0–5 points)
Present Health History/Illness
(20 points)
All required criteria included. No errors.
(18–20 points)
One required element missing.
(16–17 points)
Two required elements missing.
(14–15 points)
Required elements missing.
(0–13 points)
Health Beliefs and Practices
(15 points)
All required criteria included. No errors.
(13–15 points)
One required element missing.
(11–12 points)
Two required elements missing.
(9–10 points)
Required elements missing.
(0–8 points)
Medications
(20 points)
All required criteria included. No errors.
(18–20 points)
One required element missing.
(16–17 points)
Two required elements missing.
(14–15 points)
Required elements missing.
(0–13 points)
Past History
(20 points)
All required criteria included. No errors.
(18–20 points)
One required element missing.
(16–17 points)
Two required elements missing.
(14–15 points)
Required elements missing.
(0–13 points)
Emotional History
(15 points)
All required criteria included. No errors.
(13–15 points)
One required element missing.
(11–12 points)
Two required elements missing.
(9–10 points)
Required elements missing.
(0–8 points)
Family History
(20 points)
All required criteria included. No errors.
(18–20 points)
One required element missing.
(16–17 points)
Two required elements missing.
(14–15 points)
Required elements missing.
(0–13 points)
Psychosocial/ Occupational History
(15 points)
All required criteria included. No errors.
(13–15 points)
One required element missing.
(11–12 points)
Two required elements missing.
(9–10 points)
Required elements missing.
(0–8 points)
Roles and Relationships
(15 points)
All required criteria included. No errors.
(13–15 points)
One required element missing.
(11–12 points)
Two required elements missing.
(9–10 points)
Required elements missing.
(0–8 points)
Ethnicity and Culture
(10 points)
All required criteria included. No errors.
(10 points)
No more than one required element missing.
(8–9 points)
More than two required elements missing.
(6–7 points)
Required elements missing.
(0–5 points)
Spirituality
(5 points)
All required criteria included. No errors.
(5 points)
No more than one required element missing.
(4 points)
More than two required elements missing.
(3 points)
Required elements missing.
(0–2 points)
Self-Concept
(5 points)
All required criteria included. No errors.
(5 points)
No more than one required element missing.
(4 points)
More than two required elements missing.
(3 points)
Required elements missing.
(0–2 points)
Review of Systems
(20 points)
All required criteria included. No errors.
(18–20 points)
Two to three required elements missing. Did not include information about functional patterns of each system.
(16–17 points)
Three required elements missing. Total body systems and/or functional patterns missing.
(14–15 points)
Greater than three required elements missing. Total body systems and/or functional patterns missing.
(0–13 points)
Clarity of Writing
(10 points)
Organized logically and written clearly with good structure.
(9–10 points)
Lacks some organization and clarity. Uses words such as frequently, increased, decreased.
(8 points)
Lacks logical organization; difficult to read. Uses words such as frequently, increased, decreased.
(7 points)
Lacks logical organization; difficult to read. Many spelling errors.
(0–6 points)
Total Points Possible = 200 points