FUNDAMENTALS OF NURSING
HEALTH HISTORY ASSESSMENT

1. CLIENT PROFILE:
   1. Demographic information:
      1. Name/Initials
      2. Gender
      3. Marital status
      4. Age
      5. Where does client live:
      6. Birthdate/birthplace
      7. Occupation:
   2. Your initial impression of client
2. DEVELOPMENTAL HISTORY
   1. Developmental level
      1. What theorist?
      2. Where should client be for age?
      3. Where is client actually?
      4. What may contribute to client’s developmental progression?
3. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
   1. Client’s perception of own health.
   2. Illness history
      1. Chief complaint: (CC):
      2. History of present complaint:
      3. Treatments/medications
      4. Past illnesses and hospitalizations
      5. Allergies
   3. Prevention practices?
   4. Does client maintain routine exams, follow-up, etc.
   5. Does client follow recommendations of provider? If no, what prevents it?
4. NUTRITIONAL-METABOLIC PATTERN
   1. Weight? Recent loss or gain?
   2. Daily food intake.
   3. Daily fluid intake
   4. Drug and alcohol consumption
   5. Problems that may contribute to nutrional problems (eg swallowing difficulty, dentures,
   6. Skin, tissue, mucous membrane appearance.
5. ELIMINATION PATTERN
   1. Bowel Habits
   2. Bladder habits
   3. Any changes recently
6. ACTIVITY-EXERCISE PATTERN
   1. Physical mobility problems
   2. Fatigue level
   3. Self care ability
   4. Recreation and leisure activity pattern
   5. Does client complete own ADLs?
   6. Does client care for own living space?
   7. Problems that may interfere with activity (e.g. mobility, Shortness of breathe)
7. SEXUALITY-REPRODUCTIVE PATTERN
   1. Is client sexually active?
   2. Does client practice safe sex (i.e. disease transmission protection)
   3. Is client satisfied with activity level?
   4. Any history of sexual abuse?
   5. Menstrual history: age onset, problems, age menopause
   6. Does client do breast/testicle self-exam? Regular PAP and mammogram?
8. SLEEP-REST PATTERN
   1. Sleep habits: time to bed, time up
   2. Does client feel rested after sleep?
   3. Methods to promote sleep and relaxation (incl. medications)
   4. Sleep problems (e.g. early awakening, frequent awakening, etc)
9. SENSORY-PERCEPTUAL PATTERN
   1. Ability to taste, see, feel, hear, smell
   2. Any aids required for senses?
   3. Oriented to person, place, time?
   4. Pain? Where. Level on 1-10 scale (10 high).
   5. Does client experience hallucination? Delusions? Illusions?
   6. Does client experience obsessions? Phobias?
10. COGNITIVE PATTERN
    1. Is memory intact? Long and short term.
    2. Ability to concentrate.
    3. Decision-making capacity?
    4. Education level
    5. Insight into own situation
    6. General level of knowledge
11. ROLE-RELATIONSHIP PATTERN
    1. Marital status. If widowed/divorced/separated, how long?
    2. Have client describe the relationship.
    3. Any significant losses?
    4. Social supports? Friends, organizations, etc.
    5. Family support. Availability, etc.
12. SELF-PERCEPTUAL/SELF CONCEPT PATTERN
    1. Any perceived threats to self?
    2. Mood, affect.
    3. Is client assertive re: own needs?
    4. Client’s perceived level of control over situations?
    5. Self-worth, self-esteem. Have client describe.
    6. Body image.
13. COPING-STRESS PATTERN
    1. Current stresses or life challenges
    2. Recent major life changes (include residential)
    3. Coping strategies
    4. Resources to deal with stress.
14. VALUE-BELIEF PATTERN
    1. Ethnic/cultural background. Does client identify with them?
    2. Religious affiliation and importance to client
    3. What religious practices does client have? Do they bring comfort?
    4. How does client understand their spirituality?

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