Health Assessment Guide

BIOGRAPHICAL DATA
Question Rationale
What is your name, address, and
telephone number?
How old are you? What is your date of
birth? Note if the client is a male or
female
What is your marital status?
What is your educational level and where
are you employed?
HISTORY OF PRESENT HEALTH CONCERN
What is your most urgent health concern
at this time? Why are you seeking health
care?
Are you experiencing any other health
problems? Do you have headaches?
Describe. Do you ever have troubled
breathing or heart palpitations.
PERSONAL HEALTH HISTORY
Have you ever received medical treatment
or hospitalization for a mental health
problem or received any type of
counselling services? Explain.
Have you ever had any type of head
injury, meningitis, encephalitis, or a
stroke? What changes in your health did
you notice as a result of these?
Do you have headaches? Describe.
Have you ever served on an active duty in
the armed forces? Explain.
FAMILY HISTORY
Is there a history of mental health
problems (anxiety, depression, bipolar
disorder, schizophrenia or Alzheimer’s
disease in your family?

How are they treated? Was the treatment

effective?
LIFESTYLE AND HEALTH PRACTICES
Does your present health concern affect
your activities of daily living? Describe a
typical day. Describe your energy level.
Describe your normal eating habits.
Describe your daily bowel elimination
pattern.
Describe your sleep patterns.
Describe any exercise regimens.
Do you drink caffeinated beverages?
If so how many per day?
Do you take any prescribed or over-the-
counter medications?
Do you drink alcohol? If so, what type, how
much and how often?
Do you use recreational drugs such as
marijuana, tranquilizers, barbiturates, crack
or cocaine? If yes, how much do you use
and how often?
Have you been exposed to any
environmental toxins?
What religious affiliations do you have?
What religious activities are important to
you? What religious affiliated practices do
you participate in on a regular basis?
How do you feel about yourself and your
relationship with others?
Describe your support systems and how are
you using those at this times?
What do you perceive as your role in your
family or relationship with your significant
other? Who do you care for on a daily
basis?
Describe the current stressors in your life.
How do you feel about the future? Have
you ever had thoughts of hurting yourself or
doing away with yourself?

Nutritional Assessment Guide

HISTORY OF PRESENT HEALTH CONCERN

What are your height and normal weight?
Have you lost or gained a considerable
amount of weight recently? How much?
Over what period of time?
Are you now or have you been on a
specific diet recently? How did you decide
which diet to follow?
How much fluid do you drink each day?
How much of it is water? How many of
these beverages that you consume daily
contain sugar, artificial sweetener, caffein
or alcohol?
Can you recall what you ate in the last 24
hours? In the last 72 hours?
Any recent changes in appetite, taste, or
smell? Any recent difficulty chewing or
swallowing?
Have you had any recent occurrences of
vomiting, diarrhea, or constipation?
PERSONAL HEALTH HISTORY
Do you have food allergies and/or food
that you cannot eat? If so, please explain
what they are and your symptoms.
Do you have chronic illness?
Have you experienced any recent trauma,
surgery, or serious illness?
What current medications, natural herbs,
vitamins/supplements are you taking?
FAMILY HISTORY
Are any members of your family obese?
Do any closely related family members
have chronic illness such as digestive
disorders, heart disease, or diabetes?
LIFESTYLE AND HEALTH PRACTICES
Do your religious beliefs or culture have
dietary restrictions or requirements?
What do you eat on a typical day? How
much do you drink and what type of fluids
do you drink?
Do you prepare your own meals? If not,
who in your household typically assumes
responsibility?
Describe how your food is stored, cooked,
and served. How it is dated and labeled?
How often per week do you typically eat
your breakfast, lunch, and dinner away
from home?
If you eat meals away from home, in a
typical week, where do you go and which
meals do you eat?
What type of foods do you typically
purchased?
What is your weekly monetary budget for
food purchases?
Where do you typically purchase your food?
Do you take any prescribed or over-the-
counter medications?
Do you follow an exercise regimen?

Developmental Level Assessment Guidelines

BIOGRAPHICAL DATA
Question Rationale
How old are you?
Where were you born? How long you
been in this country?
Where is your place of birth? Tell me
about the places where you have lived.
When?
With what cultural group/s do you most
identify? What is your primary language?
When do you speak it? Are you fluent in
other languages?
What is your highest level of formal
education?
Discuss your history of employment. How
do you presently make a living and
maintain your everyday needs?
HISTORY OF PRESENT HEALTH CONCERN
Describe how you are feeling right now.
What concerns do you have about your
health? Describe any changes you have
recently experienced in your health.
Discuss any concerns you have about your
body weight.
What major stressors are you currently
experiencing? How do you cope with
stress? When you are having a problem,
how do you usually handle it? Does this
work? To whom do you turn when you are
having a conflict/crisis?
Do you have any trouble making
decisions?
Please give me some examples of recent
decisions you have had to make.
Tell me about life changes you have had
to make and/or need to make. How will
you make these changes?
PERSONAL HEALTH HISTORY
How would you describe yourself to
others?
What are your strengths and weaknesses?
What is the best method of learning for
you?
Have you ever been treated for a
psychological or psychiatric problem? If
so, please explain if this treatment helped
you deal with problems.
Please tell me about any prescribed
medications, herbs, or supplements you
are currently taking.
Please tell me about any over-the-counter
medication/herbs you are currently
taking.
Please tell me about your current medical
treatment or therapy you are undergoing.
Describe any changes you have recently
experienced concerning your weight,
eating, elimination patterns and sleep.
Please tell me about any allergies or
sensitivities you have.
Describe any chronic illness with which
you have been diagnosed. How has your
life changed since you were diagnosed?
FAMILY HISTORY
Whom do you consider to be your family?
Describe your life growing as a child.
Do you have brothers? Sisters?
Tell me about them and your relationship
with them.
Discuss any significant genetic
predisposition or characteristic trait or
disorder that you believe you have
inherited.