NURSING HEALTH HISTORY

(Interview Guide Sheet)

I. Biographic Data
A. Name/Alias:
B. Address:
C. Age
D. Birth Date
E. Sex
F. Race
G. Marital Status
H. Occupation
I. Religious Orientation
J. Health Care Financing and usual source of medical care

II. Chief Complaint and Reason of Visit:

A. What brought you to the hospital/clinic?
B.What is troubling you?

III. History of Present Illness

A. Ask what was the chronological sequence of events in reference to the client’s
chief complaints:
1. When was the start of the symptom?
2. How often?
3. Type of activity when before problem occurred?
4. Was help/ consultation sought?
5. Medication used?
B. Asks how the problem interfered with activities of daily living.

IV. Past History

A. Child hood diseases
B. Immunizations
C. Allergies
D. Accidents and injuries
E. Hospitalization (when and why?)
F. Medication

V. Family History of Illness

A. Health and ages of patient’s sibling, children, or ages at death and causes.
B. Illness in the family similar to the patient.
C. Familial incidence of rheumatic fever, hypertension, tuberculosis, diabetes,
mental illness, others especially as suggested by the present illness.

I. Functional Health Pattern

A. Health Perception and Health Management Pattern

1. How has the general health been?
2. Any colds in the past?
3. Most important things done to keep health? You think these things make
A difference to health? Include family, folks, and remedies if appropriate.
4. Use of cigarettes, alcohol, drugs? (Perform Breast
Examination?)
5. In the past, has it been easy to find ways to follow things
Nurses/doctors suggestions?
6. If appropriate: What do you think caused the illness? Actions
taken when symptoms were perceived? (Results of action)
 7. If appropriate: things important to you while you are here in the
hospital or clinic? How can we be most helpful?
8. Traditional Concepts of health and illness? Beliefs and practices?
(Classify what ill-health model is being used by the patient.)

B. Nutritional and Metabolic pattern

1. Typical daily food intake? (Specify) Supplements?
2. Typical daily fluid intake? (Specify)
3. Weight loss/ gain? Amount?
4. Appetite?
5. Food or eating discomfort? Diet restrictions?
6. Wound healing?
7. Skin problems? Lesions? Dryness?
8. Dental Problems?

C. Elimination Pattern.
1. Bowel elimination pattern. (Describe) Frequency? Characteristics?
Discomfort?
2. Urinary elimination pattern. (Describe) Frequency? Discomfort? Problem in
control?
3. Excessive perspiration? Odor problems?

D. Activity- Exercise Pattern

1. Sufficient energy for completing desired required activities?
2. Exercise pattern? Types? Regularity?
3. Spare time: leisure activities? Child: activities?
4. Perceived ability for (Code Level)

FEEDING GROOMING

BATHING GENERAL MOBILITY

TOILETING COOKING

BED MOBILTY HOME MAINTENACE

DRESSING SHOPPING

Level (0) - Full self-care

Level (1) - Requires use of equipment or device
Level (2) - Requires assistance or supervision from another person
Level (3) - Requires assistance or supervision from another person or device
Level (4) - Dependent and does not participate

E. Sleep- Rest Pattern

1. Approximately how many hours do you sleep at night?
2. Any problem falling asleep? Do you take any sleep medications?
3. Is your sleep continuous? Tired?
4. Take naps? When? (Morning/Afternoon)
5. What do you do for relaxation? (Watch TV, listen to radio, read, dance,
shopping)

F. Cognitive - Perceptual Pattern

1. Hearing difficulty? Hearing Aid?
2. Vision/ Wear eyeglasses?
3. Any change in memory lately?
 4 Easiest way to remember/learn things? Difficulties?
5. Any discomfort? Pain? How do you manage it?

G. Self-Perception and Self-Concept Pattern

1. How do you describe you self? Most of the time, feel good (not so good)
about yourself?
2. Changes in your body or the things you can do? Problem to you?
3. Changes in way you feel about yourself/ of your body? (Since illness
started)
4. Find things frequently make you angry? Annoyed? Tearful? Anxious? Depressed?
What helps?

H. Role – Relationship Pattern

1. Live alone? Family? Family Structure (Diagram)
2. Any Family problems you have difficulty handling? (Nuclear/Extended)
3. How does family usually handle problems?
4. Family depends on you for things? If appropriate: how are the managing?
5. If appropriate: How Family / others feel about your illness/hospitalization?
6. If appropriate: problem with children? Difficulty handling?
7. Belong to social groups? Close Friends? Feel lonely frequently?
8. Things generally go well with you at work? (School/college)? If appropriate
income sufficient to needs?
9. Feel part of (or isolated in) neighborhood where you are living?

I. Sexuality- Reproductive pattern

1. If appropriate: any changes or problems in sexual relations?
2. If appropriate: use of contraceptives? Problems?
3. Female: When menstruation started? Last menstrual period? Menstrual
problems? Para? Gravida?

J. Coping- Stress Tolerance Pattern

1. Tense a lot of the time? What helps? Use of any medicines, Drugs, alcohol?
2. What is most helpful in talking things over? Available to you now?
3. Any big changes in your life in the past year or two?
4. When you have big problems (any problems) in your life, how do you
handle them?
5. Most of the time, is this (are these) methods successful?

K. Value Belief Pattern

1. Generally get things you like out of life? Most important things?
2. Importance of religion in your life? If appropriate: does this help when
Difficulties arise?
3. If appropriate will being here interfere with any of your religious
practices?

VII. Others
1. Any other things that we have not talked about that you would
like to mention?
2. Questions?