In: Nursing
Comprehensive Health Assessment Form
Health History (5 pts total)
Biographical data: (1 pts)
No name or initial required
Age: ________ Marital status: ____M _____ S _____Sep. ____Cohab.
Birth date: _____________________ Number of dependents: ___________________
Educational level: ________________________ Gender: _____F _____ M _____Other
Occupation (current or, if retired, past): ______________________________________
Ethnicity/nationality: _____________________
Source of history (who gave you the information and how reliable is that person): _______________________________________________________________________
Present health history: (4 pts)
Current medical conditions/chronic illnesses:
Current medications:
Medication/food/environmental allergies:
Past health history: (10 pts total)
Childhood illnesses: Ask about history of mumps, chickenpox, rubella, ear infections, throat infections, pertussis, and asthma.
Hospitalizations/Surgeries: Include reason for hospitalization, year, and surgical procedures.
Accidents/injuries: Include head injuries with loss of consciousness, fractures, motor vehicle accidents, burns, and severe lacerations.
Major diseases or illnesses: Include heart problems, cancer, seizures, and any significant adult illnesses.
Immunizations (dates if known):
Tetanus _______ Diphtheria ________ Pertussis ________ Mumps ________
Rubella _______ Polio _____________ Hepatitis B ______ Influenza _______
Varicella ______ Other ____________________________________________
Recent travel/military services: Include travel within past year and recent and past military service.
Date of last examinations:
Physical examination _________ Vision ___________ Dental ___________
Family History (Genogram) (10 points)
Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any major health issues, and, if indicated, cause and age at death Present as a genogram.
Review of Systems (12 points total) Be sure to ask about symptoms specifically.
General health status (1 pt): Ask about fatigue, pain, unexplained fever, night sweats, weakness, problems sleeping, and unexplained changes in weight.
Integumentary (1 pt):
Skin: Ask about change in skin color/texture, excessive bruising, itching, skin lesions, sores that do not heal, change in mole. Do you use sun screen? How much sun exposure do you experience?
Hair: Ask about changes in hair texture and recent hair loss.
Nails: Ask about changes in nail color and texture, splitting, and cracking.
HEENT (2 pts):
Head: Ask about headaches, recent head trauma, injury or surgery, history of concussion, dizziness, and loss of consciousness.
Neck: Ask about neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the neck.
Eyes: Ask about change in vision, eye injury, itching, excessive tearing, discharge, pain, floaters, halos around lights, flashing lights, light sensitivity, and difficulty reading. Do you use corrective lenses (glasses or contact lenses)?
Ears: Ask about last hearing test, changes in hearing, ear pain, drainage, vertigo, recurrent ear infections, ringing in ears, excessive wax problems, use of hearing aids.
Nose, Nasopharynx, Sinuses: Ask about nasal discharge, frequent nosebleeds, nasal obstruction, snoring, postnasal drip, sneezing, allergies, use of recreational drugs, change in smell, sinus pain, sinus infections.
Mouth/Oropharynx: Ask about sore throats, mouth sores, bleeding gums, hoarseness, change voice quality, difficulty chewing or swallowing, change in taste, dentures and bridges.
Respiratory (1 pt):
Ask about frequent colds, pain with breathing, cough, coughing up blood, shortness of breath, wheezing, night sweats, last chest x-ray, PPD and results, and history of smoking.
Cardiovascular (1 pt.):
Ask about chest pain, palpitations, shortness of breath, edema, coldness of extremities, color changes in hands and feet, hair loss on legs, leg pain with activity, paresthesia, sores that do not heal, and EKG and results.
Breasts (1 pt.): (Remember men have breasts too)
Ask about breast masses or lumps, pain, nipple discharge, swelling, changes in appearance, cystic breast disease, breast cancer, breast surgery, and reduction/enlargement. Do you perform BSE (when and how)? Date of last clinical breast examination, and mammograms and results.
Gastrointestinal (1 pt.):
Ask about changes in appetite, heartburn, gastroesophageal reflux disease, pain, nausea/vomiting, vomiting blood, jaundice, change in bowel habits, diarrhea, constipation, flatus, last fecal occult blood test and colonoscopy and results.
Genitourinary (1 pt.):
Ask about pain on urination, burning, frequency, urgency, incontinence, hesitancy, changes in urine stream, flank pain, excessive urinary volume, decreased urinary volume, nocturia, and blood in urine.
Female/male reproductive (1 pt.):
Both: Ask about lesions, discharge, pain or masses, change in sex drive, infertility problems, history of STDs, knowledge of STD prevention, safe sex practices, and painful intercourse. Are you current involved in a sexual relationship? If yes, heterosexual, homosexual,, bisexual? Number of sexual partners in the last 3 months. Do you use birth control? If yes, method(s) used.
Female: Ask about menarche, description of cycle, LMP, painful menses, excessive bleeding, irregular menses, bleeding between periods, last Pap test and results, painful intercourse, pregnancies, live births, miscarriages, and abortions.
Male: Ask about prostate or scrotal problems, impotence or sterility, satisfaction with sexual performance, frequency and technique for TSE, and last prostate examination and results.
Musculoskeletal (1 pt.):
Ask about fractures, muscle pain, weakness, joint swelling, joint pain, stiffness, limitations in mobility, back pain, loss of height, and bone density scan and results.
Neurological (1 pt.): Ask about pain, fainting, seizures, changes in cognition, changes in memory, sensory deficits such as numbness, tingling and loss of sensation, problems with gait, balance, and coordination, tremor, and spasm.
Psychosocial Profile (10 pts)
Health practices and beliefs/self-care activities: Ask about type and frequency of exercise, type and frequency of self examination, oral hygiene practice (frequency of brushing/flossing), screening examinations (blood pressure, prostate, breast, glucose, etc.)
Nutritional patterns: Ask about daily intake (24 hour recall) and appetite.
Functional Ability: Ask if able to perform activities of daily living such as dressing, bathing, eating, toileting and instrumental activities of daily living like shopping, driving, cooking.
Sleep/rest patterns: Ask about number of hours of sleep per night, whether sleep is restful, naps, and use of sleep aids.
Personal habits (tobacco, alcohol, caffeine, and drugs): Ask about type, amount, and years used.
Environmental history: Identify environment as urban/rural, type of home (apartment, own home, condo)
Family/social relationships: Ask about significant others, individuals in home
Cultural/religious influences: Identify any cultural and religious influences on health.
Mental Health: Ask about anxiety, depression, irritability, stressful events, and personal coping strategies.
Now answer the question below: (3 pts)
Using the instructions below, identify 1 physical strength, 1 psychosocial/cognitive strength, and 1 weakness in either category. State why you think this to be true.
With the information you collected, you can begin developing an idea of a client’s weakness and strengths. What is a strength? This might be that a person’s nutritional status appears to be excellent. It may be that there is no impairment of mobility. They may have lots of friends with them so be socially active. What is a weakness? This might be that a person does have impaired mobility or perhaps imbalanced nutrition – more than or less than body requirements. It might be that they have a communication issue that you note or perhaps seem to have a depressed mood, seem alone/isolated.
Comprehensive Health Assessment Form
Health History (5 pts total)
Biographical data: (1 pts)
No name or initial required
Age: ___22_____ Marital status: ____Single _____Sep. ____Cohab.
Birth date: ________29.05.1998_____________ Number of dependents: _______0____________
Educational level: __________Masters In Immunology______________ Gender: _____Female____
Occupation (current or, if retired, past): _________Research Scholar_____________________________
Ethnicity/nationality: ______Korean_______________
Source of history (who gave you the information and how reliable is that person): _____________________The person itself gave me the infomation__________________________________________________
Present health history: (4 pts)
Current medical conditions/chronic illnesses: Alopecia Areata
Current medications: Topical Minoxidil solution
Medication/food/environmental allergies: Gluten and Dairy
Past health history: (10 pts total)
Childhood illnesses: No childhood illness
Hospitalizations/Surgeries: None
Accidents/injuries: None
Major diseases or illnesses: None
Immunizations (dates if known):
Tetanus __Y_____ Diphtheria __Y______ Pertussis ___Y_____ Mumps ___Y_____
Rubella __Y_____ Polio _____Y________ Hepatitis B ___Y___ Influenza ___Y____
Varicella __N____ Other ____________________________________________
Recent travel/military services: None
Date of last examinations:
Physical examination _________ Vision ___none________ Dental _____June 2019______
Family History (Genogram) (10 points)
Mother/Father/Siblings/Grandparents: Mother had breast cancer and Grandmother has hyperthyroid
Review of Systems (12 points total) Be sure to ask about symptoms specifically.
General health status (1 pt): Have you had any unexplainable pain recently?
Do you feel tired easily?
How many hours do you sleep per day?
How healthy a diet do you have?
Are you addicted to drinking or Smoking?
For how long do you have the autoimmune condition?
Integumentary (1 pt):
Skin: Do you experience any type of irritation when exposed in sunlight?
Hair: How severe is your hair fall due to alopecia? Has it ruined your natural texture?
Nails: Are your nails strong enough?
HEENT (2 pts):
Head: Do you have any pain or nausea feeling?
Neck: Does your Neck pain while you sit for a long time?
Eyes: Do you have a vision? If so what's your power? Do you have migraines?
Ears: Have you had your ears checked for any infections or defects?
Nose: Do you have any breathing difficulties through your nostrils?
Mouth/Oropharynx: Do you have a good teeth structure? How healthy are your teeth? Do they bleed while brushing?
Respiratory (1 pt):
Do you experience heaviness while breathing?
Cardiovascular (1 pt.):
Do you have a normal BP? Do you feel tired often?
Breasts (1 pt.): (Remember men have breasts too)
Do you feel any type of lumps in your breasts when examining them?
Are your breasts sore often?
Gastrointestinal (1 pt.):
Do you have stomach cramps often?
Do you have a good bowel movement?
How do your stools look?
Genitourinary (1 pt.):
Do you have any irritation while passing urine?
Female/male reproductive (1 pt.):
Both: Are you sexually active?
Do you experience any pain during sex?
Female: Are your periods too painful? Are your periods regular?
Musculoskeletal (1 pt.):
Do you have any joint or muscle pain on a daily basis?
Neurological (1 pt.): Are you prone to fainting? Do you feel numb often in certain areas of your body? Are you unable to remember things easily?
Psychosocial Profile (10 pts)
Health practices and beliefs/self-care activities:
How often do you workout?
How much water do you drink daily?
Do you follow good oral hygiene?
Do you meditate to relieve your stress?
Nutritional patterns: Can you tell me what you ate yesterday from the time you woke up?
since you are allergic to dairy how do you obtain your calcium intake?
Do you eat out a lot?
Functional Ability: Do you need assistance physically with anything you have to do on a daily basis?
Do you need a person to always help you with day to day simple activities?
Sleep/rest patterns: How long do you sleep per day?
Do you have difficulty falling asleep?
Have you taken any measures to help you sleep better?
Personal habits: Do you drink caffeine?
Do you smoke?
Do you drink?
Environmental history: Do you live alone?
Do you live in an urban area?
Is your area polluted a lot?
Family/social relationships: Do you live with anyone else in your family?
How good is your relationship with your family?
Cultural/religious influences: Do you have any beliefs related to your health that is linked with your religion or culture?
Mental Health: Are you depressed often?
Do you feel anxious often?
How do you cope up with mental stress?
Does your workplace stress you a lot?