Student Laboratory Guide

Chapter 3: Interviewing to Obtain a Health History

With your lab partner assuming the role of a client, conduct a comprehensive history. Your “student
client” may role-play a client with particular related symptoms and history.

Biographic Data

Date: Name: Gender: M F Race: Marital Status: S M D W

Date of Birth: Age: Occupation:

Address: Phone Number:

E-mail address:
Contact Person: Source of Data:

Reason for Seeking Care/Presenting Problem

Present Health Status

Current medical conditions/Chronic illnesses (check all that apply):

Anemia Asthma Artery Disease Arthritis, Osteo

Arthritis, Bronchitis Cholecystitis Chronic
Rheumatoid Obstructive
Pulmonary Disease
Cirrhosis Communicable Congestive Heart Coronary Heart
Diseases Failure Disease
Depression Diabetes, Type 1 Diabetes, Type 2 Diverticular
Disease
Emphysema Glaucoma Gout Hemophilia
Hernia Hypertension Irritable Bowel Multiple
Syndrome Sclerosis
Osteoporosis Parkinson’s Psoriasis Renal Failure
Disease
Seizure Disorder Thyroid Disease Venous Vision
Insufficiency Disturbance

Other: _____

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Chapter 3 Interviewing to Obtain a Health History Page 2

Female: Dysfunctional Uterine Bleeding Fibrocystic Breast Disease Premenstrual Syndrome

Male: Prostate Disease

Current medications: (include prescription, over the counter, herbs, and vitamins)
Name of Drug Dosage/Frequency Last Dose Taken Reason for Taking

Allergies to Medication/Foods/Medical Products/Other (e.g., latex, contrast, tape)

Allergic To Type of Reaction

Current medical treatments (e.g., breathing treatments, dialysis, wound dressing):

Past Health History

Childhood illnesses (check all that apply):

Measles Mumps Rubella Chicken pox

Pertussis Influenza Ear infections Throat
infections
Other (describe):_______________

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Chapter 3 Interviewing to Obtain a Health History Page 3

Name and Type Date/ Residual Problems

Year
Previous Medical
Conditions or
Problems

Previous
Hospitalizations

Surgeries

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Chapter 3 Interviewing to Obtain a Health History Page 4

Immunizations (Dates):
Immunization Date/s Immunization Date/s
Diphtheria Pneumococcal

Pertussis Measles, mumps, rubella

(MMR)
Tetanus Varicella

Inactivated poliomyelitis (IPV) Influenza vaccine

Haemophilus influenza type b Hepatitis A

(Hib)
Hepatitis B Human papillomavirus (HPV)

Meningococcal conjugate Other

vaccine (MCV)

Last examinations:
Last Examination Date Outcome
Last Physical
Last Vision
Last Dental
Other (describe)
Women Only
Last Menstrual Period
(LMP)
Last Pregnancy Gravida
Para
Abortion/Miscarriage
Last Pap Smear

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Chapter 3 Interviewing to Obtain a Health History Page 5

Family History (Indicate age and current health. If deceased, indicate age and cause of death.)
Person Age Current Health
A&W = alive and well Deceased
Chronic Problem (describe) Unk = Unknown
Mother
Father
Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Maternal Aunts / Uncles

Paternal Aunts / Uncles

Sister 1
Sister 2
Sister 3
Brother 1
Brother 2
Brother 3
Other (describe)

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Chapter 3 Interviewing to Obtain a Health History Page 6

Personal and Psychosocial History

Family/Social Relationships (significant others, individuals in home, role within family, etc.)

Diet/Nutrition (include appetite, typical food intake, dieting efforts, cravings)

Functional Ability (indicate ability to independently perform following self-care activities*)

Dressing Toileting Bathing Eating
Ambulating Shopping Cooking Housekeeping
* If unable to perform independently, describe:

Mental Health (anxiety, depression, irritability, stressful events, personal coping strategies)

Personal Habits
Tobacco use: Packs per day
Alcohol intake: Drinks per day
Illicit drug use: Describe:

Health Promotion
Exercise (type/frequency):
Self-examination (type/frequency):
Oral hygiene practice (frequency of brushing/flossing):
Date of last screening examination (blood pressure, prostate, breast, glucose):

Environment (include living and work environment)

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Chapter 3 Interviewing to Obtain a Health History Page 7

Review of Systems (check all that apply and comment below)

General Symptoms:
Pain Fatigue Weakness Fever
Problems Unexplained
sleeping changes in weight

Comments:

Integumentary System:
Change in skin Excessive Itching Skin lesions
color/texture bruising
Sores that do not Change in mole Recent hair loss Change in nails
heal or hair texture
Do you use How much sun
sunscreen? exposure do you
experience?

Comments:

Head:
Headaches Head injury Dizziness Fainting spells

Comments:

Eyes:
Change in vision Discharge Excessive Eye pain
tearing
Sensitivity to Flashing lights Halos around Difficulty
light lights reading
Do you wear If yes: Eyeglasses
corrective lense? Contact lenses?

Comments:

Ears:
Ear pain Drainage Recurrent Excessive ear
infections wax
Changes in Ringing in ears Sensitivity to Use of hearing
hearing noises device
Comments:

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Chapter 3 Interviewing to Obtain a Health History Page 8

Nose, Nasopharynx, Sinuses:

Nasal discharge Frequent Sneezing Nasal
nosebleeds obstruction
Sinus pain Postnasal drip Change in smell Snoring

Comments:

Mouth/Oropharynx:
Sore throat Sore in mouth Bleeding gums Change in taste
Trouble chewing Trouble Dental Change in voice
swallowing prosthesis

Comments:

Neck:
Lymph node Swelling or Neck pain Neck stiffness
enlargement mass in neck

Comments:

Breasts:
Pain Swelling Lumps or Change in
masses appearance
Nipple discharge

Comments:

Respiratory System:
Frequent colds Shortness of Wheezing Pain with
breath breathing
Cough Coughing up Night sweats
blood

Comments:

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Chapter 3 Interviewing to Obtain a Health History Page 9

Cardiovascular System:
Chest pain Palpitations Dyspnea Dyspnea during
sleep
Edema Coldness to Discoloration Varicose veins
extremities
Leg pain with Paresthesia
activity

Comments:

Gastrointestinal System:
Pain Heartburn Nausea/ Vomiting blood
vomiting
Jaundice Change in Diarrhea Constipation
appetite
Flatus Change in bowel
habits

Comments:

Urinary System:
Hesitancy Frequency Change in Nocturia
stream
Pain with Flank pain Blood in urine Excessive
urination urinary volume
Decreased
urinary volume

Comments:

Musculoskeletal System:
Muscle pain Weakness Joint swelling Joint pain
Stiffness Limitations in Limitations in Back pain
range of motion mobility

Comments:

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Chapter 3 Interviewing to Obtain a Health History Page 10

Neurologic System:
Pain Seizures Fainting Changes in
cognition
Changes in Problems with Tremor Spasms
memory coordination
Changes in
sensation

Comments:

Reproductive System:
Lesions Discharge Pain or masses

Comments:

Females:
Pain during Heavy No menses
menses bleeding or
prolonged
menses

Comments:

Sexual Activity:
Are you currently involved in a sexual relationship(s)?
If yes, what is the nature of the relationship(s)?
Number of sexual partners in last 3 months?
Do you protect yourself from sexually transmitted diseases (STD)?
If yes, method(s) used:
Do you use birth control?
If yes, method(s) used:

Problems with sexual activity:

Painful Change in sex Infertility Impotence
intercourse drive

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Chapter 3 Interviewing to Obtain a Health History Page 11

Comments:

Nursing Diagnoses and Collaborative Problems

Based on the subjective and objective data collected above, identify applicable nursing diagnoses and
collaborative problems.

Nursing Diagnoses Collaborative Problems

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