Biographic information is often collected during admission to a health care facility or agency and documented on a specific form; it helps to identify the patient. Depending on the health care setting, some biographic data may be collected by people other than the nurse.

Biographic data include the patient's name, address, billing, and insurance information. Additional biographical information may include sex assigned at birth, sexual orientation, gender identity, age and birth date, marital status, occupation, race, ethnic origin, religious preference, presence of an advance directive/living will, and the patient's primary health care provider.

The source of the information is also recorded. Differences in language and culture may have an effect on the quality and safety of health care. Language has been identified as contributing to health disparities, as a significant barrier to access to health care, and a barrier to quality health care and appears to increase the risks to patient safety (Ali & Watson, 2018; Chung et al., 2020; Kersey-Matusiak, 2019; Ku & Jewers, 2013). It is important to note the patient's preferred language for discussing health care as well as any sensory or communication needs.

The reason for seeking care is a statement in the patient's own words that describes the patient's reason for seeking care. This can help to focus the rest of the assessment. Ask an open-ended question, such as, “Tell me why you are here today.” Record whatever it is the person says, their description in exact words. Avoid paraphrasing or interpreting.

When taking the patient's history of present health concern, be sure to explore the symptoms thoroughly. Encourage the patient to describe and explain any symptoms. The description should include information regarding the onset of the problem; location; duration; intensity; quality/description; relieving/exacerbating factors; associated factors; past occurrences; any treatments; and how the problem has affected the patient.

A patient's past health history may provide insight into causes of current symptoms. It also alerts the nurse to certain risk factors. A past health history includes childhood and adult illnesses, chronic health problems and treatment, and previous surgeries or hospitalizations. This history should also include accidents or injuries, obstetric history, allergies, and the date of most recent immunizations. Vaccine recommendations are updated each year by the Centers for Disease Control and Prevention (CDC). Current guidelines for different age groups can be found on the CDC's website at www.cdc.gov (CDC, n.d.). Ask the patient about health maintenance screenings, such as routine mammograms and colorectal tests, including dates and results, as well as the use of safety measures. Ask the patient about prescribed and over-the-counter medications, including vitamins, supplements, and any home or herbal remedies. Include the name, dose, route, frequency, and purpose for each medication.

A person's family history will provide insight into diseases and conditions for which a patient may be at increased risk. Certain disorders have genetic links. Information regarding contact with family members with communicable diseases or environmental hazards can provide clues to the patient's current health or risk factors for health issues. This information can also identify important topics for health teaching and counseling.

Information about a patient's functional health helps to identify the effects of health or illness on a patient's self-care abilities and quality of life including the strengths of the patient and areas that need to improve (Jarvis & Eckhardt, 2020; Jensen, 2019). Psychosocial factors and lifestyle and health practices can contribute to and influence a patient's overall health and well-being. Social determinants of health, the conditions (social, economic, and physical) in the environments in which people live their lives, affect a wide range of health, functioning and quality-of-life outcomes and risks (USDHHS & ODPHP, 2020).

Obtain information about the patient's social support, interpersonal relationships, available care givers, resources, and supporters that are available to help the patient cope with alterations in health and related alterations in functioning and quality of life. Obtain information about the patient's values, beliefs, and spiritual resources; self-esteem and self-concept; and coping and stress management.

Question the patient regarding personal habits, including use of alcohol, illicit drugs, and/or tobacco; environmental and occupational hazards; and intimate partner and family/caregiver (domestic) violence.

Assess the patient's level of activity, ask about the patient's level of activity and exercise; sleep and rest; and nutrition. Ask about the patient's ability to perform activities of daily living (ADLs). Eating, bathing, dressing, and toileting are examples of ADLs. Assess the patient's ability to perform instrumental activities of daily living (IADLs). Housekeeping, meal preparation, management of finances, and transportation are examples of IADLs. Functional health may be further assessed using a formal tool, such as the Katz Index of Independence in Activities of Daily Living, which is used with older adults (Figure 3-1).

Obtain information about the patient's mental health. Regular screenings in primary care and other health care settings enable earlier identification of mental health and substance use disorders, leading to earlier treatment and care. Screenings should be provided to people of all ages, even the young and older adults (American Mental Health Counselors Association, 2017). There are many assessment tools available to assist with screening for mental health disorders. Specific tools are available to screen for depression or suicide, for example, and to be used with specific populations, such as adolescents or older adults. The Patient Health Questionnaire-9 (PHQ-9), the most common screening tool to identify depression, is one example of a mental health assessment tool (Figure 3-2).

Use neutral and inclusive terms (e.g., partner) and a nonjudgmental manner to obtain information about the patient's sexual history, sexual activity, gender identity, and sexual orientation. This information will help identify the needs of individual patients and provide patient-centered, culturally considerate care (Altarum Institute, 2019; Cahill et al., 2020). Some suggested strategies and essential health questions related to assessment of sexual health are included here (Altarum Institute, 2019; Cahill et al., 2020).

• In a matter-of-fact manner, inform the patient that sexual health is important to overall health and these questions are asked of everyone.
• Allow the patient the opportunity to ask questions or voice concerns.
• Assure the patient that all information is confidential.
• Ask the following questions using neutral and inclusive terms:
  • Have you been sexually active in the last year? If yes, what types of sex do you have? With men, women, or both? How many partners have you had?
  • If no, have you ever been sexually active?
  • How do you think of yourself? Lesbian, gay, heterosexual/straight, bisexual; something else (specify); don't know
  • What is your current gender identity? Male, female, female-to-male/transgender male/transgender man, male-to-female/transgender female/transgender woman, nonbinary or nonconforming, genderqueer, additional category (specify), decline to answer
  • What sex were you assigned at birth, as shown on your birth certificate? Male, female, decline to answer
  • What are your pronouns? He/him, she/her, they/their; something else (specify)
  • What do you do to protect yourself from STIs?
  • Have you been vaccinated against human papillomavirus? Hepatitis A? Hepatitis B?
  • What questions do you have about your body and/or sex?

Additional points related to assessment of sexual and reproductive health are included in Skills 3-8 and 3-9.

A review of systems is a series of questions about all body systems that helps to reveal concerns or problems as part of the health history. Questions should be adapted to the individual patient, omitting questions that do not apply and adding questions that seem pertinent, based on the setting, situation, and ongoing information as the health assessment proceeds. The nurse should avoid using medical terms and jargon and use language the patient can understand. Examples of health history questions related to each body system (review of systems) are included in the discussion of each region of the physical examination discussed in this chapter.