HEAS 1000 Health History Form
HEAS 1000 Health History Form
Client’s Biographical Data
Initials:
Identified Gender:
Age:
Birthplace:
Marital Status:
Occupation:
Student Name(s):________________________________________________________________________
NorQuest Health History Form
Collection Date:
Collection Time:
PLACE YOUR ORDER HERE
Health History Information
List your questions in each section prior to the interview
Current Health Status (a short statement about present state of health; provide chronological record of current health problems): HEAS 1000 Health History Form
Past Health History (list childhood illnesses, accidents or injuries, chronic illnesses, mental health concerns, hospitalizations, operations, obstetrical history, immunizations, most recent examination dates for physical, dental, vision and hearing):
Past Family History (ages/health concerns, age at and cause of death of blood relatives – parents, grandparents, siblings): HEAS 1000 Health History Form
Allergies:
Prescribed Medications/Over-the-Counter:
Review of Systems
List your questions in each section prior to the interview
(if no concerns, check the No column; if concerns, check the Yes column and specify with details)
History of Concern
No
Yes
if Yes, specify concerns here
Respiratory System:
Cardiovascular System:
Gastrointestinal System:
Head, Eyes, Nose and Sinuses, Mouth and Throat, Neck:
Neurological System:
Urinary System:
Genital System:
Musculoskeletal System:
Peripheral Vascular System:
Integumentary System (Skin, Hair, Nails):
Hematological System:
Endocrine System:
Cultural and Social Considerations
List your questions in each section prior to the interview
Cultural Health and Spiritual Practices.
(List any spiritual traditions/practices that the client feels needs to be part of their care?):
Functional Assessment
List your questions in each section prior to the interview
Activities of Daily Living (ADLs):
Instrumental Activities of Daily Living (IADLs):
Activity and Mobility:
Sleep and Rest:
Nutrition and Elimination:
Interpersonal Relationships and Resources:
Coping and Stress Management:
Smoking History, Alcohol and Substance Use:
Environmental Hazards:
Occupational Health:
Perception of Health
Describe the client’s perception of their health:
Indicate what the client feels are their two primary areas of health concern:
Please thank your client at the end of the interview for volunteering their time to help you develop your data collection skills!
Areas of Health Promotion
This section to be completed without your client present
Indicate here what you think are 3 areas of health concern relevant to assessment findings. Recommend strategies and resources for each of the areas identified.
Practical Nurse
HEAS 1000, June 2019
HEAS 1000 Health History Assignment Rubric
Total: / 100
Criteria Category
3 2 1 0
Biographical Data All required data is
present.
Data contains
omissions or is absent.
Health History Information
Current Health Status Data is
comprehensive for
the system. Includes
all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include some
follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off
topic, limited or
not always
appropriate.
Data is inadequate
or absent. Questions
are inadequate,
inappropriate or
absent.
Past Health History Data is
comprehensive for
the system. Includes
all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include some
follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off
topic, limited or
not always
appropriate.
Data is inadequate
or absent. Questions
are inadequate,
inappropriate or
absent.
Family History Data is
comprehensive for
the system. Includes
all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include some
follow up on
abnormalities
identified.
Data is nonspecific or
incomplete.
Questions are
somewhat off
topic, limited or
not always
appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Allergies and Current
Medications
Data is
comprehensive for
the system. Includes
all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include some
follow up on
abnormalities
identified.
Data is nonspecific or
incomplete.
Questions are
somewhat off
topic, limited or
not always
appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Criteria Category
3 2 1 0
Review of Systems
Respiratory System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Cardiovascular System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Gastrointestinal System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
does not provide
rationale.
Head, Eyes, Nose and
Sinuses, Mouth and
Throat, Neck
Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Neurological System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Urinary System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there
is/is not a problem
with the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Genital System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Musculoskeletal System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Peripheral Vascular
System
Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Integumentary System
(Skin, Hair, Nails)
Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Hematological System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Endocrine System Data is
comprehensive for
the system. Includes
all pertinent
assessment
questions with follow
up on any
abnormalities
identified AND
Identifies if there is/is
not a problem with
the system with
rationale.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May or
may not include
some follow up on
abnormalities
identified OR
Identifies if there
is/is not a problem
with the system BUT
does not provide
rationale.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Does not identify if
there is/is not a
problem with the
system and does
not provide
rationale.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Criteria Category
2 1 0
Cultural and Social Considerations
Cultural Health and
Spiritual Practices
Data is comprehensive, astute
and insightful for the section.
Questions are relevant,
meaningful and appropriate for
the section.
Data is satisfactory and
contains basic information
for the section. Questions
are satisfactory and
appropriate for the section.
Data is inadequate or
absent. Questions are
inadequate, inappropriate or
absent.
Criteria Category
3 2 1 0
Functional Assessment
Activities of Daily Living
(ADLs)
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Instrumental Activities
of Daily Living (IADLs)
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Activity and Mobility Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Sleep and Rest Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Nutrition and
Elimination
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Interpersonal
Relationships and
Resources
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Coping and Stress
Management
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Smoking History,
Alcohol and Substance
Use
Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Environmental Hazards Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Occupational Health Data is comprehensive
for the system.
Includes all pertinent
assessment questions
with follow up on any
abnormalities.
Data is satisfactory
for the system.
Includes majority of
pertinent
assessments. May
or may not include
some follow up on
abnormalities
identified.
Data is non-specific
or incomplete.
Questions are
somewhat off topic,
limited or not
always appropriate.
Data is inadequate or
absent. Questions are
inadequate,
inappropriate or
absent.
Criteria Category
3 2 1 0
Perception of Health
Client’s Perception of
Health
Comprehensive and
concise data is
provided for the
section. Questions
are relevant,
meaningful and
appropriate for the
section.
Satisfactory and basic
data is provided for
the section.
Questions are
satisfactory and
appropriate for the
section.
Data is incomplete
or minimal for the
section. Questions
are somewhat off
topic, limited or
not always
appropriate.
Data is inadequate
or absent. Questions
are inadequate,
inappropriate or
absent.
Client’s Health Concerns Comprehensive and
concise data is
provided for the
section. Questions
are relevant,
meaningful and
appropriate for the
section.
Satisfactory and basic
data is provided for
the section.
Questions are
satisfactory and
appropriate for the
section.
Data is minimal
and limited for the
section. Questions
are off topic,
limited or not
always
appropriate.
Data is inadequate
or absent. Questions
are inadequate,
inappropriate or
absent.
Practical Nurse
HEAS 1000, June 2019
Areas of Health Promotion
Health Promotion
Identificat
