Kingdom of Saudi ‫المملكة العربية السعودية‬

Arabia Ministry of ‫وزارة التعليم‬

Education University of ‫جامـعـة حـائل‬
Hail College of Nursing ‫كلية التمريض‬

Health Assessment& Physical Examination Practical - NUR

214 History Taking Assignment

Student Name: Student ID:

Date: Instructor Name:
Allotted Grade: Given Grade:
Demonstrate effective interviewing techniques to elicit pertinent subjective data
ILOs #: 2.3
necessary for history-taking and for comprehensive data collection.
Accurately document patient history and physical assessment findings using proper
ILOs #: 2.4
medical terminology

I. Patient Profile (2 marks):

Patient’s Name: Gender:
Age: Birth date/ place:
Marital Status: Address:
Religion: Race:
Ethnicity: Source of Data:
Date of interview:

II. Chief complaint/ Reason for seeking care (CC) (1 marks):

(One or two major symptoms + their last occurrence)

III. History of Present Illness (3marks):

(To obtain all details related to the chief complaint. Abbreviated as PQRST)
P (Palliative & Provocative):
Palliative/what can decrease the symptom:
Provocative/ what can increase the symptom:
Q (Quality/ how can you describe the symptom)

R (Region & Radiation):

Region/ where has the symptom occurred on your body:
Radiation/ does it radiate to other parts of the body. If yes, where:
S (Severity/ on a scale of 1-10, how much severe is your symptom, with 10 being the most severe)

T: Timing
Onset/ when & how did the pain or symptom start
Duration/ for how long does it last:

Page 1 of

Accredited University by the ASIC Accredited BSN Program

on March 27, 2017 by AHPGS on February 15,
 Kingdom of Saudi ‫المملكة العربية السعودية‬
Arabia Ministry of ‫وزارة التعليم‬
Education University of ‫جامـعـة حـائل‬
Hail College of Nursing ‫كلية التمريض‬

Health Assessment& Physical Examination Practical - NUR

214 History Taking Assignment

Frequency/ how many times a day does it happen:

A (Associated factors/ was the symptom associated with other symptoms)

IV. Current medications (Prescribed by physician/doctor) (1 mark):

1.
2.
3.

V. Past Health History (3 marks):

Problems in Growth and Development:

Common Childhood illnesses:

Immunizations:
The name of the disease/vaccination:
The number of injections/doses:
The ages when administered:
The dosage (was the dosage of the vaccinations lessened or did they give it to the patient fully):

Vaccination not given:

Cause (why not given):
Previous Screening Tests:
Test Name:
Test Date:
Test Result:
Serious Accidents, Injuries, Illnesses, Treatments:
Cause:
Date:
Treatment:
Surgical operations/ pervious hospitalization:
Cause:
Date:
Treatment:
Allergies
Does the patient have allergies from food, medication, any other agents like pets, or house hold
products?

What is the reaction?

Page 2 of

Accredited University by the ASIC Accredited BSN Program

on March 27, 2017 by AHPGS on February 15,
 Kingdom of Saudi ‫المملكة العربية السعودية‬
Arabia Ministry of ‫وزارة التعليم‬
Education University of ‫جامـعـة حـائل‬
Hail College of Nursing ‫كلية التمريض‬

Health Assessment& Physical Examination Practical - NUR

214 History Taking Assignment
VI. Personal & Social History (4 marks):
Occupation:
Education level (last year of schooling):
Current house-hold:
Primary Care Provider:
Personal interests:
Hours of sleep and arising:
Regularity of stools and urination/ how many times a day:
Monthly income:
Health Insurance:
Smoking: Cigarettes/ day
Legal/ illegal, over the counter drugs (OTC): type, frequency, rout, & rationale.
1.
2.
3.
Seat belt (yes/no):
Regular Exercise:
Type (walking, swimming, running, gym, ect.):
Frequency (daily, weekly):
Duration (how many hours):
Dietary considerations and restrictions:
Consideration (Food preferred/like to eat):
Restrictions (Food dislike or not allowed to eat):

VII. Family History (3 marks):

Used primarily to discover any hereditary or familial diseases in the family members
Draw a Family Tree: Grandparents, parents, siblings, mate, children, and grandchildren.
Indicate health status of each as age and (alive or dead), cause of death and significant illnesses or
problems.

VIII. Review of Body Systems (3 marks): (see guidelines for more details)

Page 3 of

Accredited University by the ASIC Accredited BSN Program

on March 27, 2017 by AHPGS on February 15,
 Kingdom of Saudi ‫المملكة العربية السعودية‬
Arabia Ministry of ‫وزارة التعليم‬
Education University of ‫جامـعـة حـائل‬
Hail College of Nursing ‫كلية التمريض‬

Health Assessment& Physical Examination Practical - NUR

214 History Taking Assignment

For Instructor Use Only

Evaluator Name: Evaluator Signature
Checked by: Auditor Signature:

Page 4 of

Accredited University by the ASIC Accredited BSN Program

on March 27, 2017 by AHPGS on February 15,