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

Identification

Identifies 3 areas of

health concern

relevant to

assessment findings.

Identifies 2 areas of

health concern

relevant to

assessment findings.

Identifies 1 area of

health concern

relevant to

assessment

findings.

Information is absent.

Health Promotion

Recommendations

Recommends

strategies to assess 3

areas of health

concern identified

with rationale.

Recommends

strategies to assess 2

areas of health

concern identified

with rationale.

Recommends

strategies to assess

1 areas of health

concern identified

with rationale.

Information is absent.

Health Promotion

Resource

Recommendations

Recommends 2 or

more resources to

address health

promotion needs.

Recommends 1

resources to

address health

promotion need.

Information is absent

Criteria Category

3 2 1 0

Writing Conventions and Appearance

Appearance Data/information is

typewritten, uses

consistent and clear

organizational

structure

throughout the

form. Workload

distribution is

indicated

throughout the

form (if applicable).

Data/information is

typewritten, uses

some consistent

organizational

structure throughout

most of the form.

Workload distribution

is indicated

throughout most the

form (if applicable).

Data/information

is typewritten,

but lacks

organizational

structure

throughout the

form. Workload

distribution is

indicated

throughout most of

the form (if

applicable).

Data/information is not

typewritten or lacks

clear and consistent

organizational

structure throughout

the form. Workload

distribution is not

included on the form (if

applicable).

Writing Conventions

(spelling, grammar,

punctuation,

capitalization)

Free of writing

convention errors.

Relatively free of

writing convention

errors.

There are a significant

amount of writing

convention errors.

 

 

HEAS 1000 Health History Assignment (20%)

This assignment is divided into three parts. You may choose to work with one partner, or work

individually. Please read through all of the instructions before you begin. HEAS 1000 Health History Form

Purpose:

To provide the student with an opportunity to practice performing a comprehensive health history on a

client. This will be done on an adult of the student’s own choosing. Areas of health concern will be

identified to determine health promotion needs in conjunction with the client.

You will be assessed on how you apply an understanding of the following general learning outcomes:

• conduct a health history interview of a client HEAS 1000 Health History Form

• validate and document the findings of the health history

• determine health promotion and disease prevention needs requiring client teaching

Instructions:

Part 1 – Interview Preparation:

1. Find a client, with a stable medical health condition, who is willing to participate in your health

history assignment and meets the criteria below:

a. an adult aged 16-64 (e.g., friend, family member or peer who is not your partner in this

assignment) or,

b. an older adult aged 65-up (e.g., friend, family member)

2. Provide the client with the following background information prior to setting up an interview. It

is important to communicate to the client the process and purpose of this interview:

a. no personal identifiers will be recorded on the form (only the client’s initials will be

recorded)

b. the interview process is private and client’s recorded information is confidential

c. the interview may take approximately one hour

d. the purpose of this assignment is to help me (the student) practice collecting health

history data from a client

e. if the client feels uncomfortable answering a question, indicate the reason why (if

provided), otherwise record the data as ‘client declined’ for that question

3. In consultation with your client, decide on a date, time and private location to conduct the

interview.

4. Use the Health History Form provided in Moodle for recording the data. Note: during the

interview you may be recording data in handwritten form.

5. Prior to the interview research and prepare appropriate questions for each section. Refer to the

Jarvis textbook for sample questions (textbook page numbers are listed in Part 2 of this

assignment).

Practical Nurse

HEAS 1000, June 2019 2

a. type all interview questions in each section of the form so that you are prepared and on

topic

b. the quality of your questions will be assessed as part of this assignment

6. If working with a partner, indicate on the Health History Form in each section which person is

asking the questions and which person is recording the information. Both partners are required

to lead the interview process by taking turns asking questions and you must distribute the

workload evenly, each person taking on 50% of the workload.

7. Make sure you and your partner (if applicable) have a printed copy of the form.

Part 2 – The Interview:

8. Record data in each section listed on the form. If the client indicates that there are ‘no issues’ in

a section, indicate that response beside the question. If the client was uncomfortable

responding to a section, indicate that response beside the question.

All of the following sections must contain questions and assessment data:

a. Biographical Data (only: initials, identified gender, age, birthplace, marital status,

occupation, collection date/time), p. 62-63 HEAS 1000 Health History Form

b. Health History Information, p. 63-65

c. Review of Systems, p. 65-68

d. Cultural and Social Considerations (related to health and health care), p. 65 & chapter 3

e. Functional Assessment, p. 68-70 (if you are choosing an older adult, refer also to chapter

31)

f. Perception of Health

9. Conduct the health history interview with your client

10. After collecting the health history data, ask the client the following questions and record it in the

Perception of Health section of the form:

a. to describe their perception of their health

b. to identify two primary areas of health concern and ask the client why these areas of

concern were identified

11. At the end of the interview, remember to thank your client for his/her participation in this

assignment.

Part 3 – Areas of Health Promotion:

12. After the interview has been completed, indicate what three areas you feel should be addressed

with health promotion materials/teaching recommendations for the client. (Note: your areas of

health promotion may not be the same as the client’s). Provide rationale why you choose the

three areas and identify health promotion strategies and resources for each area. Record this in

the Areas of Health Promotion section of the form.

Submission requirements:

All data collection on the Health History Form must be typewritten, well-organized and utilize proper

writing conventions (see rubric). Submit your assignment to the Health History Assignment dropbox in

Practical Nurse HEAS 1000 Health History Form

HEAS 1000, June 2019 3

Moodle. If you are working with a partner, only one person is required to submit the Health History

Form (HHF).

• Working with a partner: one person is required to submit the Health History Form to

the Moodle dropbox naming the file with the two last names of the partners.

Example of file name: HHF Smith_Williams.docx

• Working individually: submit the Health History Form with your last name Example of

file name: HHF Smith.docx

Assessment:

You will be assessed using the assignment rubric created as part of this assignment package. The rubric

is located as a PDF file in the assignment dropbox. Feedback about your assignment will be provided in

Moodle gradebook. HEAS 1000 Health History Form