NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA FROM THE CLIENT

QUESTIONS

BIOGRAPHICAL DATA

NAME

GENDER

ADDRESS, PHONE NUMBER

DATE AND PLACE OF BIRTH

NATIONALITY OR ETHNICITY

MARITAL STATUS

RELIGIOUS OR SPIRITUAL PRACTICES

PRIMARY AND SECONDARY LANGUAGES SPOKEN, WRITTEN, AND READ, BIRTH

LANGUAGE

EDUCATIONAL LEVEL

OCCUPATION AND WORKING STATUS

WHO LIVES WITH THE CLIENT? IDENTIFY SIGNIFICANT OTHERS

CAREGIVERS AND SUPPORT PEOPLE FOR THE CLIENT

REASON FOR SEEKING HEALTH CARE

1. WHAT IS YOUR MAJOR HEALTH CARE OR CONCERN?

2. ARE YOU COMFORTABLE WITH SEEKING CARE FROM THIS ORGANIZATION? PAST
EXPERIENCES GOOD OR NOT?

HISTORY OF PRESENT HEALTH CONCERN (USE COLDSPA WHEN APPROPRIATE)

1. CHARACTER OF SYMPTOM OR CONDITION

2. ONSET (WHEN DID IT BEGIN; BETTER? WORSE? SAME?)

3. LOCATION (WHERE AND DOES IT RADIATE?)

4. SEVERITY (ON SCALE OF 1-10?)

5. PATTERN (WHAT MAKES IT BETTER? WORSE?)

6. ASSOCIATED FACTORS (OTHER ASSOCIATED SYMPTOMS? EFFECT ON LEISURE OR

EXERCISE?)

PAST HEALTH HISTORY

PROBLEMS AT BIRTH?

CHILDHOOD ILLNESSES?

IMMUNIZATIONS TO DATE?

ACUTE OR CHRONIC ADULT ILLNESSES (PHYSICAL, EMOTIONAL, MENTAL)

SURGERIES?

PREGNANCIES? BIRTHS? MISCARRIAGES? ABORTIONS?

ACCIDENTS? INJURIES?

PROLONGED PAIN OR PAIN PATTERNS?

MEDICATIONS

ALLERGIES?

FAMILY HEALTH HISTORY

RECALL AS MANY GENETIC RELATIVES AS POSSIBLE (PARENTS, GRANDPARENTS,

SIBLINGS) WITH AGE, LONGEVITY, CHRONIC ILLNESSES (. E., HEART DISEASE,
STROKE, DIABETES, CANCER, ARTHRITIS,ALZHEIMER'S)

REVIEW OF SYSTEMS
SWEATING, RASHES, LESIONS, BALDING, DANDRUFF, CONDITION OF NAILS
SKIN, HAIR, AND NAILS: SKIN COLOR, TEMPERATURE, CONDITION, EXCESSIVE

HEAD AND NECK: HEADACHE, SWELLING, STIFFNESS OF NECK, DIFFICULTY

SWALLOWING, SORE THROAT, ENLARGED LYMPH NODES

QUESTIONS

EYES: VISION, EYE INFECTIONS, REDNESS, EXCESSIVE TEARING, HALOS AROUND

LIGHTS, BLURRING, LOSS OF SIDE VISION, MOVING BLACK SPOTS/SPECKS IN VISUAL
FIELDS, FLASHING LIGHTS, DOUBLE VISION, AND EYE PAIN

EARS: HEARING, RINGING, OR BUZZING, EARACHES, DRAINAGE FROM EARS,

DIZZINESS, EXPOSURE TO LOUD NOISES
MOUTH, THROAT, NOSE, AND SINUSES: CONDITION OF TEETH AND GUMS; SORE
THROATS; MOUTH LESIONS; HOARSENESS; RHINORRHEA; NASAL OBSTRUCTION;
FREQUENT COLDS; SNEEZING OR ITCHING OF EYES, EARS, NOSE, OR THROAT; NOSE
BLEEDS; SNORING

THORAX AND LUNGS: DIFFICULTY BREATHING, WHEEZING, PAIN, SHORTNESS OF

BREATH DURING ROUTINE ACTIVITY, ORTHOPNEA, COUGH OR SPUTUM,
HEMOPTYSIS, RESPIRATORY INFECTIONS

BREASTS AND REGIONAL LYMPHATICS: LUMPS OR DISCHARGE FROM NIPPLES,

DIMPLING OR CHANGES IN BREAST SIZE, SWOLLEN OR TENDER LYMPH NODES IN
AXILLA

HEART AND NECK VESSELS: LAST BLOOD PRESSURE, ECG TRACING OR FINDINGS,
CHEST PAIN OR PRESSURE, PALPITATIONS, EDEMA

PERIPHERAL VASCULAR: SWELLING, OR EDEMA, OF LEGS AND FEET; PAIN;

CRAMPING; SORES ON LEGS; COLOR OR TEXTURE CHANGES ON THE LEGS OR FEET

ABDOMEN: INDIGESTION, DIFFICULTY SWALLOWING, NAUSEA, VOMITING,

ABDOMINAL PAIN, GAS, JAUNDICE, HERNIAS

MALE GENITALIA: EXCESSIVE OR PAINFUL URINATION, FREQUENCY OR DIFFICULTY

STARTING AND MAINTAINING URINARY STREAM, LEAKING OF URINE, BLOOD
NOTED IN URINE, SEXUAL PROBLEMS, PERINEAL LESIONS, PENILE DRAINAGE, PAIN
OR SWELLING IN SCROTUM, DIFFICULTY ACHIEVING AN ERECTION AND/OR
DIFFICULTY EJACULATING, EXPOSURE TO SEXUALLY TRANSMITTED INFECTIONS

FEMALE GENITALIA: SEXUAL PROBLEMS, SEXUALLY TRANSMITTED

DISEASES; VOIDING PROBLEMS (E.G., DRIBBLING, INCONTINENCE); REPRODUCTIVE

DATA SUCH AS AGE AT MENARCHE, MENSTRUATION (LENGTH AND REGULARITY OF
CYCLE), PREGNANCIES, AND TYPE OF OR PROBLEMS WITH DELIVERY, ABORTIONS,
PELVIC PAIN, BIRTH CONTROL, MENOPAUSE (DATE OR YEAR OF LAST MENSTRUAL
PERIOD), AND USE OF HORMONE REPLACEMENT THERAPY

ANUS, RECTUM, AND PROSTATE: BOWEL HABITS, PAIN WITH DEFECATION,

HEMORRHOIDS, BLOOD IN STOOL, CONSTIPATION,DIARRHEA

MUSCULOSKELETAL: SWELLING, REDNESS, PAIN, STIFFNESS OF JOINTS, ABILITY TO

PERFORM ACTIVITIES OF DAILY LIVING, MUSCLE STRENGTH

NEUROLOGIC: GENERAL MOOD, BEHAVIOR, DEPRESSION, ANGER, CONCUSSIONS,

HEADACHES, LOSS OF STRENGTH OR SENSATION, COORDINATION, DIFFICULTY
SPEAKING, MEMORY PROBLEMS,STRANGE THOUGHTS AND/OR ACTIONS,
DIFFICULTY LEARNING
QUESTIONS

LIFESTYLE AND HEALTH PRACTICES PROFILE

DESCRIPTION OF TYPICAL DAY

"PLEASE TELL ME WHAT AN AVERAGE OR TYPICAL DAY IS FOR YOU. START WITH
AWAKENING IN THE MORNING AND CONTINUE UNTIL BEDTIME."

NUTRITION AND WEIGHT MANAGEMENT

• "WHAT DO YOU USUALLY EAT DURING A TYPICAL DAY? PLEASE TELL ME THE
KINDS OF FOODS YOU PREFER, HOW OFTEN YOU EAT THROUGHOUT THE DAY, AND
HOW MUCH YOU EAT."

• "DO YOU EAT OUT AT RESTAURANTS FREQUENTLY?" • "DO YOU EAT ONLY WHEN
HUNGRY? DO YOU EAT BECAUSE OF BOREDOM, HABIT, ANXIETY, DEPRESSION?"

• "WHO BUYS AND PREPARES THE FOOD YOU EAT?" • "WHERE DO YOU EAT YOUR
MEALS?"

• "HOW MUCH AND WHAT TYPES OF FLUIDS DO YOU DRINK?"

ACTIVITY LEVEL AND EXERCISE

• "WHAT IS YOUR DAILY PATTERN OF ACTIVITY?" • "DO YOU FOLLOW A REGULAR

EXERCISE PLAN? WHAT TYPES OF EXERCISE DO YOU DO?"
• "ARE THERE ANY REASONS WHY YOU CANNOT FOLLOW A MODERATELY
STRENUOUS EXERCISE PROGRAM?"
• "WHAT DO YOU DO FOR LEISURE AND RECREATION?"
• "DO YOUR LEISURE AND RECREATIONAL ACTIVITIES INCLUDE EXERCISE?"

SLEEP AND REST

• "TELL ME ABOUT YOUR SLEEPING PATTERNS."

• "DO YOU HAVE TROUBLE FALLING ASLEEP OR STAYING ASLEEP?"

• "HOW MUCH SLEEP DO YOU GET EACH NIGHT?"

• "DO YOU FEEL RESTED WHEN YOU AWAKEN?"

• "DO YOU NAP DURING THE DAY? HOW OFTEN AND FOR HOW LONG?"

• "WHAT DO YOU DO TO HELP YOU FALL ASLEEP?"

SUBSTANCE USE
• "HOW MUCH BEER, WINE, OR OTHER ALCOHOL DO YOU DRINK ON THE AVERAGE?"

• "DO YOU DRINK COFFEE OR OTHER BEVERAGES CONTAINING CAFFEINE (E.G.,

COLA)? IF SO, HOW MUCH AND HOW OFTEN?"

• "DO YOU NOW OR HAVE YOU EVER SMOKED CIGARETTES OR USED ANY OTHER
FORM OF NICOTINE? HOW LONG HAVE YOU BEEN SMOKING/DID YOU SMOKE? HOW
MANY PACKS PER WEEK? TELL ME ABOUT ANY EFFORTS TO QUIT."

• "HAVE YOU EVER TAKEN ANY MEDICATION NOT PRESCRIBED BY YOUR HEALTH
CARE PROVIDER? IF SO, WHEN, WHAT TYPE, HOW MUCH, AND WHY?"

• "HAVE YOU EVER USED, OR DO YOU NOW USE, RECREATIONAL DRUGS? DESCRIBE
ANY USAGE." • "DO YOU TAKE VITAMINS OR HERBAL SUPPLEMENTS? IF SO, WHAT?"

QUESTIONS

SELF-CONCEPT AND SELF-CARE RESPONSIBILITIES

. "WHAT DO YOU SEE AS YOUR TALENTS OR SPECIAL ABILITIES?"

• "HOW DO YOU FEEL ABOUT YOURSELF? ABOUT YOUR APPEARANCE?"

• "CAN YOU TELL ME WHAT ACTIVITIES YOU DO TO KEEP YOURSELF SAFE,

HEALTHY, OR TO PREVENT DISEASE?"

"DO YOU PRACTICE SAFE SEX?"

• "HOW DO YOU KEEP YOUR HOME SAFE?"

• "DO YOU DRIVE SAFELY?"

• "HOW OFTEN DO YOU HAVE MEDICAL CHECKUPS OR SCREENINGS?”

• "HOW OFTEN DO YOU SEE THE DENTIST OR HAVE YOUR EYES (VISION)
EXAMINED?"

SOCIAL ACTIVITIES

"WHAT DO YOU DO FOR FUN AND RELAXATION?"

• "WITH WHOM DO YOU SOCIALIZE MOST FREQUENTLY?"

• "ARE YOU INVOLVED IN ANY COMMUNITY ACTIVITIES?"

• "HOW DO YOU FEEL ABOUT YOUR COMMUNITY?"

• "DO YOU THINK THAT YOU HAVE ENOUGH TIME TO SOCIALIZE?"

• "WHAT DO YOU SEE AS YOUR CONTRIBUTION TO SOCIETY?"

RELATIONSHIPS

"WHO IS (ARE) THE MOST IMPORTANT PERSON(S) IN YOUR LIFE? DESCRIBE YOUR
RELATIONSHIP WITH THAT PERSON."

• "WHAT WAS IT LIKE GROWING UP IN YOUR FAMILY?"

• "WHAT IS YOUR RELATIONSHIP LIKE WITH YOUR SPOUSE?"

• "WHAT IS YOUR RELATIONSHIP LIKE WITH YOUR CHILDREN?"

• "DESCRIBE ANY RELATIONSHIPS YOU HAVE WITH SIGNIFICANT OTHERS."

"DO YOU GET ALONG WITH YOUR IN-LAWS?"

"ARE YOU CLOSE TO YOUR EXTENDED FAMILY?"

. "DO YOU HAVE ANY PETS?"

• "WHAT IS YOUR ROLE IN YOUR FAMILY? IS IT AN IMPORTANT ROLE?"

• "ARE YOU SATISFIED WITH YOUR CURRENT SEXUAL RELATIONSHIPS? HAVE THERE
BEEN ANY RECENT CHANGES?"

VALUES AND BELIEF SYSTEM

"WHAT IS MOST IMPORTANT TO YOU IN LIFE?"

"WHAT DO YOU HOPE TO ACCOMPLISH IN YOUR LIFE?"

• "DO YOU HAVE A RELIGIOUS AFFILIATION? IS THIS IMPORTANT TO

YOU?"
• "IS A RELATIONSHIP WITH GOD (OR ANOTHER HIGHER POWER) AN IMPORTANT
PART OF YOUR LIFE?"

"WHAT GIVES YOU STRENGTH AND HOPE?"

QUESTIONS

EDUCATION AND WORK

• "TELL ME ABOUT YOUR EXPERIENCES IN SCHOOL OR ABOUT YOUR EDUCATION.

• "ARE YOU SATISFIED WITH THE LEVEL OF EDUCATION YOU HAVE?

DO YOU HAVE FUTURE EDUCATIONAL PLANS?"

• "WHAT CAN YOU TELL ME ABOUT YOUR WORK? WHAT ARE YOUR
RESPONSIBILITIES AT WORK?"

• "DO YOU ENJOY YOUR WORK?"

• "HOW DO YOU FEEL ABOUT YOUR COWORKERS?"

• "WHAT KIND OF STRESS DO YOU HAVE THAT IS WORK RELATED? ANY MAJOR
PROBLEMS?"

• "WHO IS THE MAIN PROVIDER OF FINANCIAL SUPPORT IN YOUR FAMILY?"

• "DOES YOUR CURRENT INCOME MEET YOUR NEEDS?"

STRESS LEVELS AND COPING STYLES

• "WHAT TYPES OF THINGS MAKE YOU ANGRY?"

• "HOW WOULD YOU DESCRIBE YOUR STRESS LEVEL?"

"HOW DO YOU MANAGE ANGER OR STRESS?"

"WHAT DO YOU SEE AS THE GREATEST STRESSORS IN YOUR LIFE?"

• "WHERE DO YOU USUALLY TURN FOR HELP IN A TIME OF CRISIS?"

ENVIRONMENT

• "WHAT RISKS ARE YOU AWARE OF IN YOUR ENVIRONMENT SUCH AS IN YOUR

HOME, NEIGHBORHOOD, ON THE JOB, OR ANY OTHER ACTIVITIES IN WHICH YOU
PARTICIPATE?"

• "WHAT TYPES OF PRECAUTIONS DO YOU TAKE, IF ANY, WHEN PLAYING CONTACT

SPORTS, USING HARSH CHEMICALS OR PAINT, OR OPERATING MACHINERY?"

• "DO YOU BELIEVE YOU ARE EVER IN DANGER OF BECOMING A VICTIM OF

VIOLENCE? EXPLAIN."