CONDUCTING HEALTH INTERVIEW

OR NURSING HEALTH HISTORY

Vital Signs:

Temp:
BP:
HR:
RR:
S/U:

I. Biographical Data
1. Name
2. Address
3. Phone
4. Gender
5. Provider of History (Patient or other)
6.Birthdate
7. Place of Birth
8. Race or Ethnic Background
9. Primary or secondary languages (spoken or written)
10. Marital Status
11. Religious or Spiritual Practices
12. Educational Level
13. Occupation
14. Significant others or support person (availability)

II. History of Present Concern

1. Character
2. Onset
3. Location
4. Duration
5. Severity
6. Pattern
7. Associated factors

III. Past Health History

1. Problems at birth
2. Childhood Illnesses
3. Immunization
4. Adult Illness
5. Surgeries
6. Accidents
7. Prolonged pain or patterns
8. Allergies
9. Physical, emotional, social or spiritual weaknesses
10. Physical, emotional, social or spiritual strengths

IV. Family Health History

1. Age of Parents
2. Parents Illnesses and Longevity
3. Grandparent’s illnesses and Longevity
4. Aunts and Uncles Illnesses and Longevity
5. Children’s ages and illnesses and Longevity
V. Lifestyle and Health Practices
1. Description of a typical day
2. Nutrition and weight management
3. 24-hour dietary intake (food and fluids)
4. Who purchases and prepares meals
5. Activities on a typical day
6. Exercise habits and patterns
7. Sleep and rest habits and patterns
8. Use of medications and other substances
9. Self-concept
10. Self-care responsibilities
11. Social activities for fun and relaxation
12. Relationships with family, significant others and pets
13. Values, religion, affiliations and spirituality
14. Past, current and future plans for education
15. Types of work, level of job satisfaction and work stressors
16. Finances
17. Stressors in life, coping strategies used
18. Residency, type of environment, neighborhood and
environmental risks.