1. Find a patient, such as a friend or family member, to conduct an entire health history interview.
2. Use the Health History Guideline attatched to gather patient information.
3. Type the history data in a Word document.
4. Your homework should have:
   • factual information.
   • Subjective, meaning that you are only to document what the patient tells you.
   • Written professionally and concisely.
   • Typed in APA style Links to an external site.format with title page, margins, page numbers, headings, subheadings, and citations.

THIS IS THE ATTACHMENT: Health History Guideline

NUR3069 Page 1 of 4

Use this guide to gather patient information for the Comprehensive Health History Assignment.

Subject Criteria Possible Points

Patient Demographics • Gender, age, ethnicity, and other social

demographics as indicated (self-pay, Insurance) 5

Chief Complaint

• In the patient’s own words, describe one or more symptoms or concerns that cause the patient to seek care.

• Elaborate on the chief complaint; describe how each symptom developed.

• Include the patient’s thoughts and feelings about the illness.

5

History of Present

Illness

• Appropriate dimensions of cardinal symptoms are listed (including location, severity, quality, setting, chronology, aggravating/alleviating, and associated manifestations)

• HPI narrative flows smoothly in a logical fashion

• For those students who favor mnemonics, the 8 dimensions of a medical problem can be easily recalled using OLD CARTS (Onset, Location/radiation, Duration, Character, Aggr avating factors, Relief factors, Timing, and Severity).

10

Past Medical History

• Lists childhood illnesses

• Lists adult illnesses with dates for at least three categories: medical, surgical, and psychiatric.

• Medication, Allergies

• List patient’s health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety.

5

Current Health Status • Summary of general health status related to the

present illness. 5

Health History Guideline

NUR3069 Page 2 of 4

Family History

Narrative and

Genogram

https://genopro.com/geno

gram/medical/

• Outlines or diagrams of age and health or age and cause of death of siblings, parents, grandparents, and children.

• Documents the presence or absence of specific illnesses in the family (e.g., hypertension, coronary artery disease)

• The family pedigree shows at least three generations and involves standardized symbols, which mark individuals affected with a specific diagnosis to allow for easy identification.

10

Risk Assessment

Based on Family

History

• Family history of a known or suspected genetic condition

• Ethnic predisposition to certain genetic disorders

• Consanguinity (blood relationship of parents)

• Multiple affected family members with the same or related disorders

• Earlier than expected age of onset of disease

• Diagnosis in less-often-affected sex

10

Social History

• Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur?

• Do they drink alcohol? If so, how much per day and what type of drink?

• Any drug use, past or present, should be noted.

• Work, family, friends, community support systems,

5

Past Surgical History

• Were they ever operated on, even as a child?

• What year did this occur?

• Were there any complications?

5

Health History Guideline

NUR3069 Page 3 of 4

Sexual Activity

• Do they participate in intercourse? With persons of the same or opposite sex?

• Are they involved in a stable relationship?

• Do they use condoms or other means of birth control?

• If married? The health of the spouse? If divorced? Past sexually transmitted diseases?

• Do they have children? If so, are they healthy? Do they live with the patient?

5

Work/Hobbies/Other

• What sort of work does the patient do?

• Have they always done the same thing? Do they enjoy it?

• If retired, what do they do to stay busy? Any hobbies?

5

Review of Systems

(ROS)

• Document the presence or absence of common symptoms related to each central body system.

• Consider asking a series of questions going from “head to toe.”

• The questions asked to reflect an array of standard and critical clinical conditions (heart disease, diabetes, arthritis) explicitly prompt the patient,

• Format o General/skin/sleep o HEENT o Respiratory o Cardiovascular o Musculoskeletal o Endocrine o Gastrointestinal and Urinary o Neuro/psych

10

Prevention and Health

Promotion

• List at least one prevention activity.

• List at least three health promotion recommendations.

10

Health History Guideline

NUR3069 Page 4 of 4

APA Guidelines &

Writing Style

• APA (title page, margins, page numbers, headings, subheadings, citations); spelling; writing straightforward, concise, and professional.

10

Total 100

Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!

This assignment requires you to interview a real patient (friend, family, or someone you know) and document their health history professionally in APA format. You are not analyzing the data, just recording it subjectively — only what the patient tells you.

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✅ Step 1: Prepare for the Interview

• Print or open the Health History Guideline so you can follow each section during your interview.

• Remind your patient that this is for educational purposes only and that no identifying details will be published.

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✅ Step 2: Gather Patient Information

Follow the sections listed in the guideline. Ask the patient questions in their own words, and document exactly what they say.

Here’s how to structure your Word document:

Title Page (APA Style)

• Title of assignment

• Your name

• Institution

• Course name and number

• Instructor’s name

• Due date

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I. Patient Demographics

• Document gender, age, ethnicity, insurance/self-pay status.
  (Example: “Patient is a 45-year-old Hispanic female, insured through employer.”)

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II. Chief Complaint

• Write exactly what the patient says.
  (Example: “I’ve been having constant headaches for the last two weeks.”)

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III. History of Present Illness (HPI)

• Use OLD CARTS (Onset, Location, Duration, Character, Aggravating/Relieving factors, Timing, Severity).
  (Example: “Headaches began two weeks ago, located in the front of the head, dull aching pain, worsens with stress, relieved by ibuprofen, occurs daily, pain 6/10.”)

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IV. Past Medical History

• Childhood illnesses.

• Adult illnesses (medical, surgical, psychiatric).

• Medications, allergies.

• Health maintenance (immunizations, screenings, lifestyle).

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V. Current Health Status

• Patient’s general statement of their health.
  (Example: “Overall I feel healthy, except for the headaches.”)

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VI. Family History + Genogram

• Write ages, health conditions, or causes of death for parents, siblings, grandparents, and children.

• Include at least 3 generations (draw a genogram if possible using Genopro Medical Genogram Tool).

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VII. Risk Assessment

• Highlight risks such as genetic conditions, ethnic predispositions, early onset of disease, etc.

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VIII. Social History

• Tobacco, alcohol, drugs, work, support system.

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IX. Past Surgical History

• List surgeries, years, and complications.

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X. Sexual Activity

• Partners, relationships, contraception, STD history, marital status, children.

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XI. Work/Hobbies/Other

• Occupation, hobbies, retirement activities.

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XII. Review of Systems (ROS)

• Document system-by-system symptoms or lack of symptoms.
  (Example: “No chest pain, no shortness of breath, positive for frequent headaches.”)

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XIII. Prevention and Health Promotion

• List 1 prevention activity (e.g., “annual mammogram”)

• List 3 health promotion recommendations (e.g., exercise, diet, sleep hygiene).

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✅ Step 3: Write Your Summary Report

• Keep the tone professional, concise, and clinical.

• Do not add analysis—only report what the patient shared.

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✅ Step 4: APA Formatting

• Use Times New Roman, 12 pt, double spacing, 1-inch margins.

• Include headings/subheadings for each section.

• Include page numbers in the top right.

• Cite scholarly references if you mention prevention/promotion strategies (CDC, WHO, scholarly nursing journals).

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📚 Helpful Resources

• APA Style Guide

• CDC Prevention Resources

• Genopro Medical Genogram Tool