NorQuest Health History Form

This document is the NorQuest Health History Form for practical nurse students. It includes client's biographical data, health history information, past health history, allergies, medications, and more. The form provides a comprehensive overview of the client's health status and helps healthcare professionals in assessing and providing appropriate care.

Practical Nurse
Student Name(s):________________________________________________________________________
NorQuest Health History Form
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):
The client (B.K.) has been suffering from blood pressure. I initiated the discussion by asking some of the current issues faced by
her.
How are you and what issues are you facing concerning your present health state?
She had been facing some issues with her blood pressure. Although, it was not active while i was examining her but
according to her, the issue related to her blood pressure would emerge at any point of time and was terribly bad.
Apart from this, she felt good and healthy. I had to take her vital sign examination so i asked for her permission. It
would help me to examine the present health state in a more vital and analyzed manner.
Vital signs:
Height: 148cm
Weight: 70 kg
Body temperature: 35.8 C
Pulse rate: Regular and strong pulse with 75 beats per minutes
Respiratory rate: 15 breaths per minute
Blood pressure: High (140/90 mmHg)
She informed me that she had a healthy lifestyle and there have been not any issue related to her health apart
from this high blood pressure issue. She rated her blood pressure as 3/10.
Chronological record of health: high blood pressure
Explain about your current health condition in a little more detail. When and how did it started?
The client had been suffering from high blood pressure since a couple of months. It first examined during a regular
health check up on 3rd of January 2019. Initially the issue emerged as a minor increase in her blood pressure and
she thought it would be ok after a few days of rest and proper diet. But it remained active and was investigated by
the physical examination. Her physical examination conducting doctor had advised her to take rest and also to
follow a healthy food habit but there have been no further improvements in the present condition.
What makes you feel better and worst in respect of your daily activities and the increased blood pressure?
The client was facing issues like Severe headache, Chest pain while conducting physical exercises such as climbing
stairs and lifting weights. These activities were very painful at times. She admitted to be using prescribed medicines
as well as medically recommended exercises which is the main source to make her feel better in pain.
What is the exact point of pain?
The pain is specifically in the chest, head and it is static since the day of its origin. There has been no any change in
the location of pain.
HEAS 1000, November 2017 1
Collection Date: 5 April 2019
Collection Time: 1800
Client’s Biographical Data
Initials: B.K.
Identified Gender: Female
Age: 40
Birthplace: Nigeria (West Africa)
Marital Status: Married
Occupation: Health care professional

Practical Nurse
Is it too much intense or mild?
It is intense while climbing stairs and running but apart from these activities the pain is not active.
Quality and severely:
What are some of the most specific symptoms and is the pain constant or it is getting worst?
It mostly pains when some of the previously mentioned physical activities are performed and rest of the times its
fine. The pain is constant and it’s neither getting good nor getting worst.
What are the issues you face in your daily life due to your current high blood pressure issue?
She is not able to climb upstairs at her home and couldn’t get to her office as she had been advised to take rest.
Timing:
When was the first time you faced issues with this pain?
She first had the pain the very next day while she was working in her kitchen. She was having issues while trying to
lift something. That was the very first time when it was felt by her.
How often do you experience this pain?
She fees the pain while conducting any physical activity which involves intense movements like climbing stairs and
lifting weights.
Aggravating and relieving factors:
What triggers the pain and what makes it worse?
Physical activities trigger the pain and those involving much stress make it worst. While activities like driving,
household work and general movements are not quite impactful on triggering the pain. She is afraid to conduct any
physical activities any more as she thinks it would land her in serious health trouble.
What are the precautions or reliving techniques used by you to counter the impacts?
The patient has been using medicines and medicated exercises and these are evident to provide her some relief.
Associated factors:
Is there any other part of the body affected by this pain? Does it travel?
The client said its still at the same spot as it was on the first day. It doesn’t travel to any further body parts. It is also
constant in terms of pain intensity.
Understand:
What do you understand about this pain?
The client considers it a result of increased blood pressure as the main cause of this pain.
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):
Do you have any history of mumps, measles, strep throat and pertuses?
No
Did you have any serious illness such as scarlet fever, inflammation or pain in joints?
None
Accidents or injuries:
Have you ever had any accident injuries, fractures or any other related issue?
No
Serious or chronic illness:
HEAS 1000, November 2017 2

Practical Nurse
Did you have any issues like hypertension, diabetes, or any blood related issue?
No
Hospitalizations:
Have you ever been hospitalized previously? If yes what was the issue and how it was treated?
She had been hospitalized once while she was expecting a child. It was for a week and everything went well. She
was discharged after a week after she delivered as baby through normal provisions.
Mental health concerns:
Do you have any mental health issues or concerns?
No
Surgeries:
Have you ever had any surgery? If yes, what was the exact issue, please provide important information
associated with it?
No surgeries till date.
Obstetrical history:
How many pregnancies and deliveries have been conducted? Did you undergo any abortion and what is the
number of Childs living?
She have had one and only delivery. There have been no any abortion and the child is living and healthy.
Immunization
Do you remember having any immunization related to polio, measles, and mumps? At what age did you undergo
these immunizations?
She couldn’t remember any initial immunization process but has been tested for tuberculosis and HIV during the
initial months of 2017 which resulted in to negative reports.
Most recent medical examination date:
Have you recently visited any physical, vision, dental, hearing and any other such examination process?
She had undergone a regular medical examination two days after the pain generated and the reports reflected
increased blood pressure. The report reflects normal information apart from this particular issue.
Past Family History (ages/health concerns, age at and cause of death of blood relatives – parents, grandparents, siblings):
Are your parents alive? What are their health conditions? Do you have any family history of diseases?
The patient had both of her parents alive and healthy. They have been living at her birthplace (West Africa). She
has one sibling who is younger to her and there is no any evidence of some family history of illness or diseases.
Are any of your family members suffering from heart diseases, strokes, diabetes, cancer, alcoholism or any such
major issue?
No
Allergies:
HEAS 1000, November 2017 3

Practical Nurse
Do you consider yourself allergic to anything like food, environmental agent or medication? Please provide some
evident examples if yes?
No allergies
Prescribed Medications/Over-the-Counter:
Did you take any prescribed medication? What is the issue related to it and how often do you need these
medications
The patient has been using medicines and medication based exercises.
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: Do you have any historical concern related to lung disease such as bronchitis,
cough, sputum with blood, asthma?
No such concerns
Did you took any X-Ray examination recently?
No.
Do you smoke or have any history of smoking?
None
Cardiovascular
System:
Did you have any precordial pain related issues from past like palpitation,
cyanosis and acute chest pain? Is there any availability of unusual sound
between heartbeats?
The client does not have any precordial pain history and but there are issues like
irregular heartbeat rate currently.
Did you get any electrocardiogram test recently?
No
Gastrointestinal
System:
Do you have any issue rated to your gastrointestinal system?
None
Did you have any history of abdominal disease like gallbladder, appendicitis or
colitis?
She doesn’t have any history of these issues.
HEAS 1000, November 2017 4

Practical Nurse
Head, Eyes, Nose
and Sinuses, Mouth
and Throat, Neck:
Do you have any head injuries, headaches or dizziness issues?
None
Do you have any issue related to vision?
No
Do you have any issue related to hearing or ear related malfunctions?
None
Do you have any nasal infection or issues?
No infections or allergies
Did you face any issue with your mouth like swallowing issues or anything like
that?
None
Do you have any neck rated issue such as pain neck or movement issues?
No
Neurological
System:
Did you ever experience any seizures, strokes, fainting or blackouts?
None
Do you have any childhood tremor?
No
Do you have any history of mental health disruptions?
No
Urinary System: Do you have any issue with your urination system?
None
Do you have any history of urinary disease?
No
Genital System: At what age did you get your menstruation for the first time?
She was 15 when she got her first periods
Is there any issue with your menstruation?
None
Musculoskeletal
System:
Do you have any issue with your joints?
None
HEAS 1000, November 2017 5

Practical Nurse
Do you use mobility aids? Is there any history of arthritis or gouts?
She is not using any mobility aids.
Peripheral Vascular
System:
Are you having any issue regarding coldness, swelling or numbness?
No.
Is there any dislocation related issue with your hand or legs?
None
Integumentary
System (Skin, Hair,
Nails):
Do you have any skin, hair or nails rated issues or any history of it?
None
Hematological
System:
Is there any bleeding from skin, bruising, and exposure to radiation or reaction?
No
Endocrine System: Do you have any history of diabetes or increased appetite?
No
Do you have any abnormal nervousness and shaking movement issues?
None
Nutritional (list
special diets,
allergies,
unintentional
weight loss/gain,
tube feeding, etc.):
Did you find any recent change in you weight?
Yes, she had lost 3 pounds in the last 6 months by working out and exercising.
Do you consider your eating habits healthy?
Yes
Description of meal plan
Breakfast: one fruit, coffee, eggs and cereal with milk
Lunch: she takes curry and rice or pulses with chapattis
Supper: she takes vegetable soup and bread
Dinner: she takes snacks and milk
HEAS 1000, November 2017 6

Practical Nurse
Cultural and Social Considerations
List your questions in each section prior to the interview
Spiritual, Religion
(list any spiritual or
religious
traditions/practices
that the client feels
needs to be part of
their care?):
What is the possible impact of spiritual alignment on your health conditions?
She belongs to African origin and follows Islam religion. She visits mosque every day and
prefers to be attached to god in times of weaknesses.
Cultural Health
Practices
(list any ethnic or
cultural practices
that the client feels
needs to be part of
their care):
When did you shift to Canada? Did you face any cultural challenges?
She has been living in Canada since 2010 as an immigrant. She follows a non-vegetarian food
habits and Western clothing structure. She has not faced any cultural challenge while her stay
here.
Functional Assessment
List your questions in each section prior to the interview
Activities of Daily
Living (ADLs):
Do you ever need additional help while conducting basic hygienic operations such as
bathing and oral care?
No
Instrumental
Activities of Daily
Living (IADLs):
Are you able to use different communication channels such as internet and phone lines?
Yes
Activity and
Mobility:
What is a typical day for you like? Do you find it difficult to perform your regular daily
tasks?
HEAS 1000, November 2017 7

Practical Nurse
She follows a typical working lifestyle. She cooks for herself as well as for her family and
leaves for her work. At night she has to finish her work and prepare dinner for the family. She
is not facing any of such issues in conducing these day to day operations.
Sleep and Rest: What is your regular sleeping routine like?
She generally sleeps at night for 8 full hours and there is no such issues regarding sleep
deprivation.
Nutrition and
Elimination:
Who supports you financially?
She is herself working so she can support herself and her husband is another major support
for her financial needs.
Interpersonal
Relationships and
Resources:
How is your relationship with your family and friends?
She lives with her husband and a son. She is very friendly and comfortable with her family and
friends.
Coping and Stress
Management:
How do you manage your stress issues?
She uses social media for stress relief. She also communicates with her extended family
members in Nigeria.
Smoking History,
Alcohol and
Substance Use:
Do you have any addiction history related to smoking, drinking or another drugs?
None
Environmental
Hazards:
How is your surrounding environment? How often do you communicate with your
neighbors?
She has a beautiful neighborhood and also has good relationships with her neighbors.
Occupational
Health:
Where do you work?
She works at a medical facility.
Do you deal with any medical hazard like chemicals or anything like that?
None
Do you like your job?
HEAS 1000, November 2017 8

Practical Nurse
She really likes her job
Perception of Health
Describe the client’s perception of their health:
What is like being healthy according to you?
She defines health as a state of mind and body which can be used to perform day to day operations without facing
any minor or major issues.
Is there any health, social or cultural concern?
She has only one concern and that is her increased blood pressure.
Indicate what the client feels are their two primary areas of health concern:
The client is currently in a state of fear that her increased blood pressure can or not be controlled. She has been
impatient for finding the exact solution for this issue as she is facing difficulties while performing her day to day
operations.
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 the client’s primary health concerns and provide rationale:
The client’s primary health concern is associated with her increased blood pressure. She has been worried about
its aftermaths and thus she has been implying each of the possible solutions like eating healthy, exercising and
limiting physical activities. She has been taking rest which is a good thing but she must start practicing yoga as it
would help her gain more healthy lifestyle and this may led to improvement in the present situation. As the results
seen to be normal for all the tests done. She needs to take rest for a while and visit her physician regularly to track
the progress. She must take care of her health as she is 40 years old and her body is quite fragile in terms of health
issues.
HEAS 1000, November 2017 9

Practical Nurse
HEAS 1000, November 2017 10