<p> Health Interview Nurs 450 Health Interview and Genogram</p><p>Identifying Data</p><p>1. Initials:</p><p>2. Allergies/Response: </p><p>3. Primary Language:</p><p>4. Family Composition:</p><p>5. Home/Living Situation:</p><p>6. Physician Specialty:</p><p>7. Economic Status:</p><p>Present Health History</p><p>1. List of current Medical Problems- Identify the current problems with approximate date of onset or client age</p><p>2. List of Current Medications</p><p>3. Habits: tobacco, alcohol, street drugs- # yrs smoked, # yrs stopped, type, frequency</p><p>4. Sleep patterns- # of hours per day, naps, and quality of sleep</p><p>5. Nutritional data: Typical 3-meal diet history plus snacks</p><p>Past Medical History</p><p>1. Childhood Illness: measles, mumps, rubella, etc</p><p>2. Past injuries: fractures, lacerations, contusions</p><p>3. Hospitalizations: reason and year</p><p>4. Operations:</p><p>5. Major Illnesses:</p><p>6. Environmental exposures: coal, dust, asbestos, land fill, lead, heavy metals, insecticides, radiation, contaminated food/water</p><p>7. Travel: Recent travel out of the USA-exposures to Tb, Hepatitis A, malaria</p><p>Review of Systems 1. General Health:</p><p>2. Skin, Hair, and Nails:</p><p>3. Head and Face:</p><p>4. Eyes: </p><p>5. Ears:</p><p>6. Nose and Sinuses:</p><p>7. Mouth, Teeth, Throat:</p><p>8. Lymph Nodes: </p><p>Genogram:</p><p>Draw a three generation family tree (genogram). This is to include the patient, his siblings, parents and grandparents. Consent- A Consent form must be signed by the individual !</p><p>Genorgram and discussion: State ages and health status of persons diagrammed. Indicate if alive and well or note illnesses for each. If dead, state cause and age. Inquire about heart disease, high blood pressure, cancer, diabetes , birth defects, epilepsy, asthma, AIDS, mental illness, etc. Please use a Key to indicate the following: sex, deceased or living, and health history- ie CAD, DMII.</p><p>NOTE: When assessing a patient, it is not appropriate to ask the patient only direct questions. Information is obtained by observing verbal and non-verbal behaviors and making inferences. </p>