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):

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):

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

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:

Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

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:

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
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.
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 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.
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.
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.
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.
Cultural and Social Considerations Cultural Health and Spiritual Practices Data is comprehensive and includes client’s input with specific identified traditions/practices as requested. Data is satisfactory but may not include identified traditions/practices. Data is nonspecific or incomplete. Data is inadequate or absent.
Functional Assessment Activities of Daily Living (ADLs) Data is comprehensive for the system. Includes all pertinent assessment questions with follow up on any abnormalities identified. 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 identified. 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.
The response demonstrates thorough understanding of the health assessment process and is able to accurately and comprehensively gather relevant data for all systems and areas. The response is organized, clearly presents information, and effectively utilizes the nursing process to prioritize and address identified issues. It includes insightful and comprehensive follow-up on abnormal findings, taking into account the client’s input and specific cultural/social considerations. The response also demonstrates excellent knowledge of health and medical terminology.
The response demonstrates a good understanding of the health assessment process and is able to gather relevant data for most systems and areas. It includes the necessary assessment questions and shows proficiency in using the nursing process to identify issues. The response is organized and presents information clearly, with some insightful follow-up on abnormal findings. It also shows a satisfactory awareness of health and medical terminology.
The response demonstrates a basic understanding of the health assessment process but may miss some important data in various systems and areas. It includes some of the assessment questions and attempts to use the nursing process, although with limited detail in identifying issues. The response is somewhat disorganized and may lack clarity in presenting information. It shows a limited awareness of health and medical terminology.
The response demonstrates a limited understanding of the health assessment process. It lacks significant data in most systems and areas and does not effectively use the nursing process to identify issues. The response is disorganized, unclear in presenting information, and lacks follow-up on abnormal findings. It shows a lack of awareness of health and medical terminology.
The response is minimal and lacks a coherent understanding of the health assessment process. It does not provide the necessary data for systems and areas, and there is no evidence of using the nursing process. The response is disorganized, unclear, and lacks any follow-up on abnormal findings. It shows a lack of awareness of health and medical terminology.