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

1

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NR302_Health_History_Worksheet.docx
Home>Nursing homework help>HEALTH ASSESSMENT RUA PAPERE
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

1

Applied Sciences
Architecture and Design
Biology
Business & Finance
Chemistry
Computer Science
Geography
Geology
Education
Engineering
English
Environmental science
Spanish
Government
History
Human Resource Management
Information Systems
Law
Literature
Mathematics
Nursing
Physics
Political Science
Psychology
Reading
Science
Social Science
Home
Homework Answers
Blog
Archive
Tags
Reviews
Contact
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