Current health Issues other than their previously noted main health needs/reasons for seeking care. Are there any other issues affecting your current health? Tell me more. How is that affecting you? Note. Although the patient may not have made the connection, other health issues are sometimes related to their main health need. For example, they may report a fever in addition to an earache.
	Childhood illnesses Type, timing, treatment, hospitalisations, complications, disability Tell me about any significant childhood illnesses that you had. When did it occur? How did it affect you? How did it affect your day-to-day life? Were you hospitalised? Where? How was it treated? Who was the treating practitioner? Did you experience any complications? Did it result in a disability? Note. The probing questions may be more important to ask when the illnesses may impact the patient later in life, for example, Rheumatic Heart Disease (RHD).
	Chronic illnesses Type, timing, impact, treatment, hospitalisations, complications, disability Tell me about any chronic illnesses you currently have or have had (e.g., cancer, cardiac, hypertension, diabetes, respiratory, arthritis. Note. Chronic illnesses can significantly impact a patient’s life both physically and psychosocially.
	Acute illnesses, accidents, or injuries Type, timing, treatment, hospitalisations, complications, disability Tell me about any acute illnesses that you have had. Tell me about any accidents or injuries you currently have or have had. Note. Acute and Chronic illnesses can significantly impact a patient’s life both physically and psychosocial.
	Obstetrical health Number of pregnancies, full-term deliveries, pre-term deliveries, number of living children, fertility treatments, miscarriages, termination of pregnancy, and other data related to current or past pregnancy Have you ever been pregnant? Do you have plans to get pregnant in the future? Tell me about your pregnancies. Have you ever had difficulty conceiving? How was your labour and delivery? Tell me about your postpartum experience. Were there any issues or complications? Note. These questions do not apply to all patients. Additionally, you should be aware that the feelings about pregnancy can be complex and may not always be happy.

Mental Health and Well-Being

A patient’s mental health refers to their emotional and psychological well-being that affects their day-to-day functioning. Mental health is often under-screened, which reveals a significant gap, considering that stress is pervasive in society. Mental illness includes conditions such as depression, anxiety, addiction, schizophrenia, and post-traumatic stress disorder, among others. Mental illness is a disruption in everyday function, which means a person’s employment, relationships, and civil participation can all be impaired by mental illness. It is important to assess a patient’s mental health, and if present, mental illnesses. You want to begin this component of the assessment with a statement such as, “Mental health is an important part of our lives and so I ask all patients about their mental health and any concerns or illnesses they may have.”

See below for a selection of questions and statements that you may ask patients to elicit data about their mental health. Note also that there are many other factors that influence mental health, such as violence and trauma, which are addressed under the next section, Functional Health.

Tell me about your mental health This question broadly focuses on health and invites a dialogue. The statement should not be asked in isolation or as a one-off question, as societally and culturally there are different meanings of what constitutes mental health, and a patient may not identify themselves as having mental health issues. If a patient responds “Good,” consider probing a bit further with “Tell me about how so,” or “What do you mean by good?” which allows them to respond in more depth. Tell me about the stress in your life Stress, by and large, is a relatable term that many patients have experienced and that is something they are likely more comfortable talking about than more difficult health issues because it is so ubiquitous. It’s important to be attentive to the patient’s language and consider terms they may use, such as “extreme stress,” “severe stress,” “unmanaged stressed,” or “debilitating stress,” as these may indicate an underlying mental health issue or stress that requires intervention. How does stress affect you? Understanding how stress affects the patient provides insight into the mental, physical, and social impact on them. You may need to probe about how stress affects the patient physically, mentally, and socially. How do you cope with this stress? This question invites discussion about coping strategies. It is important to be attentive to any self-harm coping strategies such as substance abuse, isolation/disengagement, food restriction, purging, cutting, compulsions, and phobias as these could indicate a mental health issue.

Functional Health

Functional health involves the assessment of the patient’s physical and mental capacity to participate in day-to-day activities. It includes assessment of:

• Activities of Daily Living (ADL) are basic tasks fundamental to everyday functioning (e.g., hygiene, elimination, dressing, eating, ambulating/moving).
• Instrumental Activities of Daily Living (iADL) are more complex daily tasks that allow patients to function independently (e.g., managing finances, paying bills, purchasing and preparing meals, managing one’s household, taking medications, facilitating transportation). Assessment of iADL may be particularly important to inquire about with adolescents or young adults who have just moved into their first place and patients who are older and/or have disabilities.

It is important to assess functional health because the data collected could expose an opportunity for preventive action and health promotion, palliation, or assistance. Because health extends beyond the absence of disease, it is important to consider broader dimensions of health as a holistic and complete assessment. You may start this section of the interview by saying, “Next, I would like to ask you some questions related to your day-to-day life and factors that affect your ability to function in your day-to-day life.” Different questions and considerations on functional health are presented below.

Nutrition Refers to food and fluid intake, financial ability to purchase food, time and knowledge to prepare and make meals, and appetite or change in appetite. You also want to elicit data related to a patient’s usual diet and goals related to their nutrition. Additionally, you need to probe so that an adequate amount of detail is obtained.

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Elimination Refers to the removal of waste products through the urine and stool. Healthcare providers refer to urinating as “voiding.” A stool is referred to as a “bowel movement.” You want to assess urine concentration, frequency, and odour. For stool, you want to assess frequency, colour, and consistency. You want to use terminology that patients understand. Thus, you may find yourself using less medicalised terms, such as “pee” and “poo” when speaking with some patients.

 

Sleep and rest Refer to a patient’s pattern of rest and sleep and any associated routines or aids. Although it varies for everyone, it is suggested that people should get approximately eight hours of sleep per night.

 

Mobility, activity, exercise Mobility refers to a patient’s ability to move around (e.g., sit up, sit down, stand up, walk). Activity and exercise refer to informal and/or formal activity (e.g., walking, swimming, yoga, strength training). Note: In addition to exercise, it is important to assess activity because some people may not engage in exercise but still have an active lifestyle (e.g., walking to school, working in a physically demanding job).

 

Violence and trauma There are many types of violence, including abuse and neglect, physical, sexual, psychological, and financial. Trauma can be a result of violence or other distressing events in a life.

 

Relationships and resources Refer to influential relationships in the patient’s life, whether positive or negative.

 

Intimate and sexual relationships Refer to sexual feelings, attractions, and preferences toward other people. It involves a combination of emotional connection and, physical companionship (holding hands, hugging, kissing) and sexual activity. It is also linked with a person’s identity and part of their physical and mental health.

 

Substance use Refers to the intake of alcohol, tobacco products (e.g., smoking, chewing tobacco), cannabis, or any illegal drugs (e.g., cocaine, heroin, meth, inhalants, fentanyl). Assess the type, frequency, quantity, and patterns while making a distinction between use and abuse. Substance misuse typically constitutes a disruption in everyday function because of a dependence on a substance (e.g., loss of employment, deterioration of relationships, loss of home or precarious living circumstances).

 

Environmental health and home/occupational/school health Environmental health refers to the safety of a patient’s physical environment, which is a determinant of health. Examples include exposure to community violence, air pollution, and insect infestations. This may include health and safety in the school and workplace (e.g., hazardous materials, noise, body mechanics).

 

Self-concept and self-esteem Self-concept refers to all the knowledge a person has about themselves that makes up who they are (i.e., their identity). Self-esteem refers to a person’s self-evaluation of these items as being worthy or unworthy. It is best to assess these items toward the end of the interview because you will already have collected data that potentially contributes to an understanding of the patient’s self-concept and self-esteem.

 

Other iADL Refers to more complex daily tasks that allow patients to function independently.

Preventative Treatments and Examinations

Assessing other preventative treatments and examinations includes gathering data on medications, examination and diagnostic tests, and vaccinations.  You might begin this section by asking the patient, “What are the ways that are most important for you to optimise your health?” (you may have already discussed this as part of the functional health section).

It is important to ask the patient about their current, past, and known future medication regime, examinations, and vaccinations to form a profile of the treatment that the patient has received and plans to receive. This information will tell you a lot about the patient’s current health status based on the care they have and will receive.

Medications Name, dose, frequency, reason for taking it, when they first started taking it, and whether they take it as prescribed. This applies to both prescribed and over-the-counter medications, such as vitamins, pain relievers, homeopathic medicines, and cannabis.

 

Examination and diagnostic dates Primary care provider (physician or nurse practitioner), specialists, blood pressure, blood tests, chest radiographic, electrocardiogram, dental, vision, or hearing.

 

Vaccinations Type, date received, and any significant reactions.

Family Health

Assessing the current and past health of a patient’s family is important because diseases sometimes have a genetic component. This data provides you with a risk profile for inherited conditions. While it is important to understand the risk and likelihood of illness based on family health, these factors do not determine health and wellness. You want to ask questions that elicit information about the health status, age, and if applicable, cause of death and age at the time of death of blood relatives (parents, grandparents, siblings, children, nieces, nephews). Questions to ask include:

Tell me about the health of your blood relatives. Do they have any chronic or acute diseases (e.g., cardiac, cancer, mental health issues)? Of any blood relatives who have passed away, do you know the cause of death? And at what age did they pass?

You also want to assess the health status of non-blood relatives and individuals that patients have had close encounters with or live with; this can be an important part of the assessment, particularly in terms of communicable diseases (i.e., diseases spread through air, food, physical contact, contaminated surfaces, and insect and animal bites). Questions to ask include:

Tell me about the health status of those you live with. Has anyone been sick recently? If so, do you know the cause? What symptoms have they had? Have you been around anyone else who was sick recently (e.g., at work, at school, in a location that involved a close encounter such as a plane or an office)?

Cultural Health

Assessing cultural health involves gathering data on factors related to a person’s cultural background that may influence their health and illness status. An open-ended question allows the patient to share what they believe to be most important.

An example You may ask, “I am interested in your cultural background as it relates to your health. Can you share with me what is important about your cultural background that will help me care for you?” Note. It is best to let patients spontaneously answer this question. Give them time to think. You should explore any factors that they choose to share (e.g., “Tell me more.” “How does that affect your health and illnesses?” “Is there anything else you want to share about how these factors act as resources in your life?”.

Assessing cultural health once meant having a checklist about different cultural groups. This approach is antiquated because it assumes culture is static and measurable. It is important to encourage each patient to speak about what is important to them. You may find that patients speak about information related to how they grew up and their way of life, their values and beliefs, traditions related to food, and their spirituality or religion, among many other things.