Student Laboratory Guide

Chapter 4
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

Name:       Gender:       Race:      

Date of Birth:       Age:    

Address:       Phone Number:      

     
Marital Status:       Contact Person:      

Occupation:       Source of Data:      

Reason for Seeking Care/Presenting Problem

     

Present Health Status

Current medical conditions/Chronic illnesses:      

Current medications:      

Medication/Food allergies:      

Current medical treatments:      

Past Health History

Childhood illnesses (check all that apply): Measles Mumps Rubella

Chicken pox Pertussis Influenza Ear infections Throat infections

Other:      

Previous medical conditions:      

Previous hospitalizations:      

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Chapter 4 Interviewing to Obtain a Health History Page 2

Accidents/Injuries:      

Surgeries:      

Immunizations (Dates):

Tetanus       Diphtheria       Pertussis       Mumps       Rubella      

Poliomyelitis       Hepatitis B       Influenza       Varicella      

Other      

Dates of last examinations:

Physical examination       Vision       Dental      

Women: LMP       Gravida     Para     Abortions/miscarriages    

Date of last pap smear       Date of last mammogram      

Family History (Indicate age and current health. If deceased, indicate age and cause of death.)

Maternal grandparents:      

Paternal grandparents:      

Mother and mother’s siblings:      

Father and father’s siblings:      

Siblings:      

Spouse and children:      

Personal and Psychosocial History

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

Diet/Nutrition (include appetite, typical food intake, etc.):      

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):      

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Chapter 4 Interviewing to Obtain a Health History Page 3

Personal Habits

Tobacco use:       Packs per      :      

Alcohol intake:       Drinks per      :      

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, etc.):      

Environment (include living and work environment):      

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

General Symptoms: Pain Fatigue Weakness Fever

Problems sleeping Unexplained changes in weight

Comments:      

Integumentary System: Change in skin color/texture Excessive bruising

Itching Skin lesions Sores that do not heal Change in mole

Recent hair loss Change in nails or hair texture

Do you use sunscreen?       How much sun exposure do you experience?      

Comments:      

Head: Headaches Head injury Dizziness Fainting spells

Eyes: Change in vision Discharge Excessive tearing Eye pain

Sensitivity to light Flashing lights Halos around lights Difficulty reading

Do you wear corrective lenses?       If yes: Eyeglasses Contact lenses

Comments:      

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Chapter 4 Interviewing to Obtain a Health History Page 4

Ears: Ear pain Drainage Recurrent infections Excessive ear wax

Changes in hearing Ringing in ears Sensitivity to noises Use of hearing device

Comments:      

Nose, Nasopharynx, Sinuses: Nasal discharge Frequent nosebleeds

Sneezing Nasal 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 swallowing Dental prosthesis

Change in voice

Comments:      

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

Neck stiffness

Comments:      

Breasts: Pain Swelling Lumps or masses Change in appearance

Nipple discharge

Comments:      

Respiratory System: Frequent colds Shortness of breath Wheezing

Pain with breathing Cough Coughing up blood Night sweats

Comments:      

Cardiovascular System: Chest pain Palpitations Dyspnea

Dyspnea during sleep Edema Coldness to extremities Discoloration

Varicose veins Leg pain with activity Paresthesia

Comments:      

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Chapter 4 Interviewing to Obtain a Health History Page 5

Gastrointestinal System: Pain Heartburn Nausea/vomiting Vomiting blood

Jaundice Change in appetite Diarrhea Constipation Flatus

Change in bowel habits

Comments:      

Urinary System: Hesitancy Frequency Change in stream Nocturia

Pain with urination Flank pain Blood in urine Excessive urinary volume

Decreased urinary volume

Comments:      

Reproductive System: Lesions Discharge Pain or masses

Females: Dysmenorrhea Menorrhagia Amenorrhea

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 STD?       If yes, method(s) used:      

Do you use birth control?       If yes, method(s) used:      

Problems with sexual activity: Painful intercourse Change in sex drive

Infertility Impotence

Comments:      

Musculoskeletal System: Muscle pain Weakness Joint swelling

Joint pain Stiffness Limitations in range of motion

Limitations in mobility Back pain

Comments:      

Neurologic System: Pain Seizures Fainting Changes in cognition

Changes in memory Problems with coordination Tremor Spasms

Changes in sensation

Comments:      

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Chapter 4 Interviewing to Obtain a Health History Page 6

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

1.       1.      

2.       2.      

3.       3.      

4.       4.      

5.       5.      

Mosby items and derived items © 2005, 2002 by Mosby, Inc.