HEALTH ASSESSMENT RUA PAPERE

NR302_Health_History_Worksheet.docx

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Chamberlain College of Nursing NR302 Health Assessment I

Health History Worksheet

This worksheet is used to assist the student in gathering and organizing information when conducting a health history.

Family Member	Description
Paternal grandfather First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Paternal grandmother First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Father First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Father’s siblings- Summary of any significant health issues
Maternal grandfather First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Maternal grandmother First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Mother First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Mother’s siblings- Summary of any significant health issues
Adult Participant First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Adult participant’s siblings Summary of any significant health issues
Adult participant’s spouse/significant other First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Adult participant’s children- Up to 4 children
Child #1 first and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Child #2 first and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Child #3 first and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Child #4 first and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:

An example

*Family Member*	*Description*
Paternal grandfather First and last initials:	RL
Birthdate:	1921
Death date:	1981
Occupation:	Retired as a coal miner
Education:	6th grade
Primary language:	English
Health summary:	He was diagnosed with chronic lung disease, diabetes, and hypertension. He died from a heart attack.
Paternal grandmother First and last initials:	ML
Birthdate:	1932
Death date:	1998
Occupation:	House wife
Education:	*Does not want to disclose*
Primary language:	English
Health summary:	Diagnosed with chronic lung disease from smoking cigarettes. Died from heart failure.

This example points to common problems among this generation on both sides of the Adult Participant’s family. Consider the potential implications this would have for the Adult Participant’s health status.

NR302_Health_History_Worksheet April 2014