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University of Ottawa
Faculty of Health Sciences - School of Nursing
Health Assessment I
NSG 1225
COMPLETE HEALTH ASSESSMENT INTERVIEW GUIDE
BIOGRAPHICAL DATA
Name ___________________________
Phone: _________________
Address______________________________________________________
Birth date _________________________
Birthplace _______________
Age __________
Gender _________
Marital status _____________
Race/ethnic origin____________________ Occupation ______________
Level of education _______________
Living arrangements (alone, residence, etc) __________________________
Functional Health Pattern: Health Perception/Management
1. Health Perception
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How would you describe your health now and during the past year?
(i.e. were there any days where you were sick and couldn’t do your usual activitites?)
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Relative to other people your age, how would you rate your overall health at the present time:
a) Excellent
b) Very good
c) Good
d) Fair
e) Poor
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Why would you rate it this way?
2. Influencing Factors: Health Management and Adherence Behaviour
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What do you do on your own to stay healthy?
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Is there anything that makes it difficult for you to follow health advice? (i.e. time, past experience
with health professionals...)
3. Health Habits: The next set of questions asks about your health habits.
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a) When were your last immunizations completed and what were they? ( Note to the student: Prior
to conducting the health assessment, you must look up the immunizations required for the
particular age group being assessed.)
Have you had any childhood diseases such as chickenpox, german measles, red measles,
mumps, polio, tuberculosis?
b)
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Do you:
operate vehicles under the influence of alcohol or other drugs?
ride with vehicle operators who are under the influence of alcohol or other drugs?
wear helmets and/or safety gear when riding a bike or roller blading?
use seatbelts or child...