Foundations Fall 2020 Name____________________
Clients Interview and Personal Health History
Questions Outcomes
Biographical Data
Name
Gender
Address, phone number
DOB and place
Nationality or ethnicity
Marital Stats
Religious or spiritual practices
Primary and secondary languages spoken,
written and read; birth language
Educational Level
Occupation and working status
Who lives with the client? Identify significant
others
Caregivers and support people for the client
Reasons for Seeking Health Care
1. What is your major health care
concern?
2. Are you comfortable with seeking
care from this organization? Past
experiences good or not?
Use COLDSPA, as listed below, for Present Health
1. Character of symptoms or conditions
2. Onset (when did it begin: better?
worse? Same?
3. Severity (on scale of 1-10)
4. Pattern (what makes it better?
worse?)
5. Associated factors (other associated
symptoms? Effect on leisure or
exercise)
Past Health History
Any problems at birth?
Childhood illnesses?
Immunizations to date?
Acute or chronic adult illnesses (physical,
emotional, mental)?
Surgeries?
Pregnancies? Births? Miscarriages?
Abortions?
Accidents? Injuries?
Prolonged pain or pain patterns?
Medications
Allergies?
Family Health History
Recall as many genetic relatives as possible
(parents, grandparents, siblings) with age,
longevity, chronic illnesses ( heart disease,
stroke, diabetes, cancer, arthritis,
Alzheimer’s)
Review of Systems
Skin, hair, and nails: Skin color, temperature,
condition, excessive sweating, rashes,
lesions, balding, dandruff, condition of nails
Head and neck: Headache, swelling, stiffness
of neck, difficulty swallowing, sore throat,
enlarges lymph nodes
Eyes: Vision, eye infections, redness,
excessive tearing, halos around lights,
blurring loss of side vision, moving black
spots/specks in visual fields, flashing lights,
double vision and eye pain
Ears: Hearing, ringing or buzzing, earaches,
drainage from ears, dizziness, exposure to
loud noises
Mouth, throat, nose, and sinuses: Condition
of teeth and gums; sore throat; mouth
lesions; frequent colds; sneezing or itching
eyes, ears, nose or throat; nose bleeds;
snoring
Thorax and lungs: Difficulty breathing,
wheezing, pain, shortness of breath during
routine activity, orthopnea, cough or sputum,
hemoptysis, respiratory infections.
Breasts and regional lymphatics: Lumps or
discharge from nipples, dimpling or changes
in breast size, swollen or tender lymph nodes
in axilla.
Heart and neck vessels: Last blood pressure,
ECG tracing or findings, chest pain or
pressure, palpitations, edema
Peripheral vascular: Swelling, or edema, of
legs and feet; pain; cramping, sores on legs;
color or texture changes on the legs or feet.
Abdomen: Indigestion, difficulty swallowing,
nausea, vomiting, abdominal pain, gas,
jaundice, hernias
Male genitalia: Excessive or painful urination,
frequency or difficulty starting and
maintaining urinary stream, leaking of urine,
blood noted in urine, sexual problems,
perineal lesions, penile drainage, pain or
swelling in scrotum, difficulty achieving an
erection and/or difficulty ejaculating,
exposure to sexually transmitted infections.
Female genitalia: Sexual problems; sexually
transmitted diseases; voiding problems
(dribbling, incontinence); reproductive data
such as age at menarche, menstruation
(length and regularly of cycle), pregnancies,
and type of or problems with delivery,
abortions, pelvic pain, birth control,
menopause (date or year of last menstrual
period), and use of hormone replacement
therapy.
Anus, rectum, and prostate: Bowel habits,
pain with defecation, hemorrhoids, blood in
stool, constipation, diarrhea
Neurologic: General mood, behavior,
depression, anger, concussions, headaches,
loss of strength or sensation, coordination,
difficulty speaking, memory problems,
strange thoughts and/or actions, difficulty
learning.
Lifestyle Profile
Description of Typical Day: “Please tell me
what an average or typical day is for you.
Start with awakening in the morning and
continue until bedtime.”
Do you drink a car?
Nutrition and Weight management:
What do you usually that during a
typical day? Please tell me the kinds
of foods you prefer, how often you
eat throughout the day, and how
much you eat.
Do you eat out at restaurants
frequently?
Do you eat only when hungry? Do you
eat because of boredom, habit,
anxiety, depression?
Who buys and prepares your meals?
In your home, where do you eat your
meals?
What fluids do you drink? How much
do you drink of alcohol per week?
How much water do you drink per
day?
Activity Level and Exercise:
Stated level of daily level of activity
Do you have a regular exercise
program?
What types of exercise to you do?
Is there a reason you cannot
participate in an exercise program?
What are your hobbies?
What do you do for recreational
activities?
Sleep and Rest:
What do you think about your sleep
pattern?
Do you have trouble falling or staying
asleep?
How many hours do you sleep each
night on the average?
Do you feel rested after a night’s
sleep?
Do you nap during the day?
Do you have a routine to help you fall
asleep?
Substance Use:
How much do you drink-beer, wine or
other alcohol on the average?
Do you drink coffee, tea, soda? How
much and how often?
Do you smoke or have you ever
smoked? What do you smoke-
cigarettes, cigars, pipe? Do you use
chewing tobacco?
Have you taken any medications that
are not prescribed by a healthcare
provider?
Do you take vitamins or herbal
supplements?
Self-concept and self-care:
How do you feel about yourself?
Do you practice safe sex?
How often do you provide in medical
checkups?
How often do you see a dentist?
How often do you have your eyes
checked?
Social Activities:
What do you do for fun?
Who do you socialize with most
often?
What do you see as your contribution
to society?
Relationships:
Who is the most important person in
your life?
Did you have a happy family life as a
child?
What is your relationship with your
significant other and your extended
family members?
Do have any pets?
What role do you have in your family?
Are you satisfied with your current
sexual relationships?
Values and Belief System:
What is most important to you in your
life?
What gives you strength and hope?
Do you believe in a higher power?
Education and Work:
1. Are you satisfied with your level of
education?
2. Tell me about your work?
3. Do you enjoy work?
4. What kind of stress do you have at
work?
5. Who provides the main financial
support?
6. Does the current income meet your
financial needs?
Stress Levels and Coping Skills:
What makes you angry?
How do you manage anger?
Do you have someone to turn to in a
crisis?
Situation:
What precautions do you take in your
home for safety?
Do you believe you are ever in danger
of becoming a victim of violence?