Assignment Purpose

This assignment aims to conduct a comprehensive health history assessment by collecting subjective data and identifying health/wellness priorities based on the findings. It seeks to recognize the interrelationships between personal data (physiological, psychosocial, cultural/spiritual, and developmental) and their impact on health and wellness. Additionally, the assignment encourages reflection on the interactive process between the nurse and the client during a health assessment.

Course Outcomes

This assignment is designed to help students achieve the following course outcomes.

CO 2: Apply prior knowledge of nursing theories and principles to integrate clinical judgment in professional decision-making and implementing the nursing process during a physical assessment. (PO 4, 8)

CO 3: Recognize how developmental stages influence physical, psychosocial, cultural, and spiritual functioning. (PO 1)

CO 4: Utilize effective communication techniques when performing a health assessment. (PO 3)

CO 6: Identify teaching/learning needs based on an individual’s health history. (PO 2, 3)


Assignment Preparation

Although it is optional, you may use a Health History Worksheet to help organize the necessary information for the Family Medical History. The assignment consists of three parts.

Health History Assessment (35 points)

Using the provided components of a health history assessment and referring to your textbook for detailed information about each category, conduct a health assessment on an individual who is not a family member or close friend and is 18 years of age or older. This restriction aims to ensure unbiased responses and avoid influencing the answers. You should inform the interviewee about the assignment, emphasize the confidentiality of the information obtained, and avoid using any identifying information.

Components to be included in the Health History:

  • Demographic data
  • Perception of health
  • Past Medical History (including medications, allergies, and vaccinations/immunizations)
  • Family Medical History
  • Review of Systems (Head-to-Chest)
  • Developmental considerations
  • Cultural considerations
  • Psychosocial considerations

In addition, consider the following aspects:

  • Identify the body system (Head-to-Chest) that would be a top priority for evaluation in a physical assessment and explain why.
  • List two teaching/learning needs based on age, psychosocial factors, cultural considerations, and lifespan concerns.
  • Identify collaborative resources such as community, family, groups, and the healthcare system that could support the individual’s health.

Please maintain confidentiality and avoid including identifying information in your assignment.


Reflection (10 points)

Conducting this Health History provided an opportunity for reflection on the entire interaction with the interviewee. To ensure effective therapeutic communication, I considered various aspects such as the environment, my approach to the individual, and the time of day. Throughout the process, I aimed to apply what I have learned and engage professionally and empathetically. Comparing my interaction with what I knew, I found that many communication techniques and principles were applicable and practical. Active listening, open-ended questioning, and non-verbal cues encouraged the interviewee to share their health history. Building rapport and establishing trust were crucial elements, and I attempted to create a comfortable and non-judgmental environment.

Several aspects of the interaction went well. The interviewee seemed comfortable and willing to provide the necessary information. Their responses were detailed and relevant to the health history assessment components. Additionally, I maintained a professional demeanor and demonstrated empathy throughout the interview. However, there were some barriers to communication that I experienced. The interviewee occasionally provided vague or incomplete answers, making obtaining a comprehensive health history challenging. I used probing techniques to encourage further elaboration and clarification to overcome this. In the future, I will refine my probing skills to ensure all necessary information is obtained.


During the interview, I encountered unanticipated challenges, such as the interviewee’s difficulty recalling specific details of their past medical history. This required me to adapt my approach by using memory prompts, such as asking about significant events or milestones, to jog their memory and obtain as much information as possible. In hindsight, I wished I had brought certain pieces of information. For example, I realized later that I had not asked about the interviewee’s social support system, which could be essential for their overall well-being. This highlights the need for a more structured and comprehensive approach in future health assessments to ensure no critical information is overlooked.

To alter my approach next time, I will develop a checklist or guide to ensure that all relevant aspects are covered during the interview. This will help me gather a more thorough health history and address potential gaps. Additionally, I will continue to enhance my communication skills and actively seek feedback to improve my interviewing techniques. In terms of written communication, I have tried to synthesize my prior knowledge, newly acquired information and demonstrate practical writing skills. I have strived to use proper grammar, spelling, and punctuation to ensure clarity and coherence in expressing my thoughts and reasoning. By adhering to these writing standards, I aim to convey my understanding of the assignment and effectively communicate my reflections and insights.