Building a Health History

Effective communication is vital to constructing an accurate and detailed patient history. A patients health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients health risks.

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following new patients:

76-year-old Black/African-American male with disabilities living in an urban setting

Adolescent Hispanic/Latino boy living in a middle-class suburb

55-year-old Asian female living in a high-density poverty housing complex

Pre-school aged white female living in a rural community

16-year-old white pregnant teenager living in an inner-city neighborhood

To prepare:

With the information presented in Chapter 1 in mind, consider the following:

How would your communication and interview techniques for building a health history differ with each patient?

How might you target your questions for building a health history based on the patients age, gender, ethnicity, or environment?

What risk assessment instruments would be appropriate to use with each patient?

What questions would you ask each patient to assess his or her health risks?

Select one patient from the list above on which to focus for this Discussion.

Identify any potential health-related risks based upon the patients age, gender, ethnicity, or environmental setting that should be taken into consideration.

Select one of the risk assessment instruments presented in Chapter 1 or Chapter 26 of the course text, or another tool with which you are familiar, related to your selected patient.

Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.

Post on or before Day 3 a description of the interview and communication techniques you would use with your selected patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowins diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.

Building a Health History

Communication is important when it comes to detailing one’s health history. Various factors such as age, gender, culture, and environment influence patient’s health. Therefore, it becomes important for any practicing nurse to consider these factors in communication strategy (Conrad, Cavanaugh & Konrad, 2012). This paper delineates on how effective communication helps in building individual health history focusing on pre-school aged white females living in a rural community.

The health related risk of the patient under study is based on age. The pre-school aged girl is depicting signs of autism. This is a mental problem that affects the communication and social skills of an individual. It is as well manifest in adult people.  One of the familiar risk assessment tools that can be used to help assess the risk of this problem in such a patient is the Pervasive Developmental Disorders Screening Test-II (PDDST-II). This tool is a form of questionnaire that aims to understand or study various early relevant behaviors in temperament, non-verbal communication, sensory responses, attachment, play, and social interaction (Frances & Carter, 2011). As indicated, this assessment tool is relevant to the patient as it helps to identify early signs of autism, hence, allowing adoption of early prevention measures.

 In building health history, interviews, questionnaires and observation will be used. The behaviors of the girl will be observed and recorded in a video for further analysis. Questionnaires will also be used to illustrate the behaviors of the girl. Interviews as well will also be carried out to elicit information from the parent and the child. Questions will be open ended to ensure gathering of more details (Seidel, Ball, Dains, Flynn, Solomon & Stewart, 2011).  The questions that will help build the history include:

  1. Do you have anyone in your family suffering from autism?
  2. What is the average performance of the girl
  3. How does she socialize  with other  children
  4. What  is  name of your parents and  your teacher
  5. Do you like playing with other children?

             History building is very important, though it can only be successful if the patient and other parties in a case like this share information pertaining to the health problem. Practicing nurses must ensure that they investigate the health problem to understand the exact course for them to tailor their treatment. Communication should be precise and clear to achieve success.


Conrad, S., Cavanaugh, J., & Konrad, S. (2012). Fostering the development of effective person-   centered healthcare communication skills: An interprofessional shared learning model,        Work, 41(3):293-301.

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