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CHS/BSN-CURR -RLEFORM-002i
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Student Name: _____________________________ Date/s of Care: _____________________________ Score: _______________

Area of Assignment _____________________________ Clinical Instructor: _____________________________

NURSING HEALTH ASSESSMENT

BIOGRAPHICAL DATA

Name ___________________________ Age/Sex _____________________ Marital Status ___________________________

Address ___________________________ Religion _____________________ Occupation ___________________________

HEALTH HISTORY
The complete health history is performed to collect as much subjective data about a client as possible. Assessment should be appropriate to your assigned patient

A. Chief Complaint/s: __________________________________________________________________________________________________

B. Impression / Admitting Diagnosis: ______________________________________________________________________________________
C. History of Present Health Concern: (using COLDSPA: detailed description of the concern; recorded in statements that reflect the client’s current symptoms as verbalized
by the client. (Character – How does it feel, look, smell, sound, etc, Onset – When did it begin? Is it better, worse, or the same since it began?, Location – where is it? Does it
radiate?, Duration – how long does it last? Does it recur?, Severity – how bad is it on a scale of 1 (barely noticeable) to 10 (worst pain ever experienced, Pattern – what makes it
better? What makes it worse?, Associated factors – what other symptoms do you have with it? Will you be able to continue doing your work or other activities (leisure or
exercise?)
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________

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D. History of Past Illness/es: Personal Health History: events that happened before the client’s admission to the healthcare facility or the current encounter with the client.

Document your findings

Birth problems
Childhood illnesses
Immunizations
Adult Illnesses
Surgeries
Accidents/Injuries
Pain
Allergies
Medication Use
Hospitalizations

E. Lifestyle and Health Practices: information details about risk behaviors (concise and comprehensive)

Guide Questions Document your findings

ADLs in a typical day “Please tell me what an average or typical day is for
you. Start with awakening in the morning and
continue until bedtime”
Diet for past 24 hours ● “What do you usually eat during a typical
day? Please tell me the kinds of foods you
prefer, how often you eat throughout the
day, and how much you eat.”
● “Do you eat out at restaurants frequently?”
● “Do you eat only when hungry? Do you eat
because of boredom, habit, anxiety,
depression?”
● “Who buys and prepares the food you eat?”
● “Where do you eat your meals?”

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● How much and what types of fluids do you

drink?”
Exercise regimen ● “What is your daily pattern of activity?”
● “Do you follow a regular exercise plan?
What types of exercise do you do?”
● “Are there any reasons why you cannot
follow a moderately strenuous exercise
program?”
● “What do you do for leisure and
recreation?”
● “Do your leisure and recreational activities
include exercise?”
Sleep and Rest ● “Tell me about your sleeping patterns”
● “Do you have trouble falling asleep or
staying asleep?”
● “How much sleep do you get each night?”
● “Do you feel rested when you awaken?”
● “Do you nap during the day? How often
and for how long?”
● “What do you do to help you fall asleep?”
Substance Use ● “How much beer, wine, or other alcohol do
you drink on average?”
● “Do you drink coffee or other beverages
containing caffeine (eg.cola?” If so, how
much and how often?”
● “Do you now or have you ever smoked
cigarettes or used any other form of
nicotine? How long have you been
smoking/did you smoke? How many packs
per week? Tell me about any efforts to
quit.”
● “Have you ever taken any medication not
prescribed by your healthcare provider? If
so, when, what type, how much, and
why?”
● “Have you ever taken any medication not
prescribed by your healthcare provider? If
so, when, what type, how much, and
why?”
● “Have you ever used, or do you now use,
recreational drugs? Describe any usage.”

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● “Do you take vitamins or herbal

supplements? If so, what?”
Self-Concept and Self-Care Responsibilities ● “What do you see as your talents or
special abilities?”
● “How do you feel about yourself? About
your appearance?”
● “Can you tell me what activities you do to
keep yourself safe, healthy, or to prevent
disease?”
● “Do you practice safe sex?”
● “How do you keep your home safe?”
● “Do you drive safely?”
● “How often do you have medical checkups
or screenings?”
● “How often do you see the dentist or have
your eyes (vision) examined?”
Social Activities ● “What do you do for fun and relaxation?”
● “With whom do you socialize most
frequently?”
● “Are you involved in any community
activities?”
● “How do you feel about your community?”
● “Do you think that you have enough time
to socialize?”
● “What do you see as your contribution to
society?”
Relationships ● “Who is (are) the most important person
(s) in your life? Describe your relationship
with that person?”
● “What was it like growing up in your
family?”
● “What is your relationship like with your
spouse?”
● “What is your relationship like with your
children?”
● “Describe any relationships you have with
significant others.”
● “Do you get along with your in-laws?”
● “Are you close to your extended family”
● “Do you have any pets?”
● “What is your role in your family?” Is it an
important role?”

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Values and Belief System
Education and Work
Stress Levels and Coping Styles
Environment
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● “Are you satisfied with your current sexual
relationships? Have there been any recent
changes?”
● “What is most important to you in life?”
● “What do you hope to accomplish in your
life?”
● “Do you have a religious affiliation? Is this
important to you?”
● “Is a relationship with God (or another
higher power) an important part of your
life?”
● “What gives you strength and hope?”
● “Tell me about your experiences in school
or about your education.”
● “Are you satisfied with the level of
education you have? Do you have future
educational plans?”
● “What can you tell me about your work?
What are your responsibilities at work?”
● “Do you enjoy your work?”
● “How do you feel about your coworkers?”
● “What kind of stress do you have that is
work related? Any major problems?”
● “Who is the main provider of financial
support in your family?”
● “Does your current income meet your
needs?”
● “What types of things make you angry?”
● “How would you describe your stress
level?”
● “How do you manage anger or stress?”
● “What do you see as the greatest
stressors in your life?”
● “Where do you usually turn for help in a
time of crisis?”
● “What risks are you aware of in your
environment such as in your home,
neighborhood, on the job, or any other
activities in which you participate?”
● “What types of precautions do you take, if
any, when playing contact sports, using
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harsh chemicals or paint, or operating

machinery?”
● “Do you believe you are ever in danger of
becoming a victim of violence? Explain.”

F. Family Health History with Genogram:

History of Heredo-Familial Diseases
____ Cancer ____ Hypertension Others (please specify):
____ Diabetes Mellitus ____ Cardiac Disease _____________________________
____ Asthma ____ Mental Disorder

Genogram (up to 3rd generation)

Legend:
- female relatives (circle)
- male relatives (square)
- deceased relative (noted by marking an X in the circle
or square and listing the age of death and cause of death)

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Genogram

EVALUATION TOOL: Nursing Assessment

UNACCEPTABLE SATISFACTORY EXCEPTIONAL

REMARKS
1-7 8-12 13-20
Health History Insufficient; Lots of missing information relating to Age/Gender appropriate; contains pertinent information but Complete; age/gender appropriate; written in logical 20
the chief complaint vital points relating to the chief complaint are missing manner
1-5 6-9 10-15 15
Genogram Genogram depicts less than 2 generations of the Genogram depicts 2-3 generations of the family; some Genogram depicts 3 or more generations of family;
family; no weights or arrows, no relationships, and weights and arrows are indicated; hazy relationships and clear weights and arrows; evident relationships and
no health history; legend is not present lacking relevant health history; legend is present relevant health history is present; legend is present;
clearly understandable and relevant
Total ___/35

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