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Building a Health History

Building a Health History

Building a Health History

Patient Scenario

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


Summary of Interview

Obtaining information about a patient is effective to provide pertinent information primarily via patient interview. The process of patient interview can be very effective when individualized, as with 55-year-old Asian female living in a high-density public housing complex.

Ball et al., suggests that building a history with a patient is essential in gaining the patient’s trust and to obtain adequate and pertinent information. They further suggest that patients from different backgrounds can be misunderstood, and efforts should be made to discern their world (Ball et al., 2019).

Even though the interview process with this patient is individualized it was conducted systematically. Effective communication considered a prime strategy for establishing good rapport. First, identify and introduce self to the patient, and address her by name, and try to remove barriers for patient to be more comfortable. Platt and Gordon believe that exchanging names, sitting down, choosing a seat in reach of patient, maintaining eye contact, and creating an environment free from obstacles, or other distractions helps to maintain comfort to execute a successful interview (Platt & Gordon, 2004).

After establishing rapport, clarifying the patient’s agenda by obtaining the patient’s concerns for discussion, for example precise symptoms, requests, and expectation. Effective listening skills was employed which allowed for patient to express herself freely and being nonjudgmental and the same time. During the interview periods of silence was observed for patient to adequately decipher what she wanted to communicate next, or just to reflect. Ball et al., agrees that the interviewer should be nonjudgmental, be an alert listener, also to respect silence which is a productive tool (Ball et al., 2019).

The interview continued with gaining detailed information about current symptoms. This was obtained by asking open ended questions about physical, medical, surgical emotional, family, economic, social and psychosocial history. With each stage or phase of her history, pertinent information was repeated for confirmation. Wu and Orlando believe that information gained on health risk assessment is helpful to identify risks for common and chronic illnesses (Wu & Orlando, 2015).

The interview ended successfully with a summary confirmation of discussion and evaluating the patient’s understanding. The opportunity was extended for patient to ask questions, expressed fears and concerns. Arrangements made for follow up plans. I also extended gratitude to my patient for her time and for accommodating this interview.

Risk Assessment Tool

The health risk assessment tool was employed for this patient. This tool was considered fitting for this patient because of her age, race coupled with her socioeconomic status of living in a high- density public complex. Because of her status, patients in this category are mainly concerned with getting by daily with little or no thoughts of developing or being at risk for being diseased.

Wu & Orlando believes that the state of progressing from health to disease, several changes transpire, that is from being healthy to presymptomatic while feeling well and totally unaware of the condition. They further believe that this risk assessment tool helps to assess an individual’s risk for the development of chronic conditions, while permitting health care providers to develop tailored care plans, preventive care, initiating tests and screening according to the developmental level of individuals, to sustain and maintain adequate health. For example, mammogram, blood works for HIV, hepatitis, cardiac profile, and other relevant tests for middle aged women (Wu & Orlando, 2015).


Targeted Questions

Thiago et al., believe that CHD and cerebrovascular accidents results from unhealthy eating habits sedentary lifestyle, smoking, and excessive drinking alcohol which contributes to almost 80% of the risk factors (Tiago et al., 2015).

Targeted questions were developed from the following based on the patient’s history, her age and lifestyle:

1. Lifestyle behaviors on tobacco, alcohol, drug use, exercise and eating habits.

2. Physical health relative to weight, blood pressure, cholesterol

3. Preventive health screenings for breast, colon cancer, heart disease, hepatitis and HIV

4. Employment, financial and insurance status

5. Emotional awareness- coping with stress, depression, expression of feelings, maintaining healthy relationships





Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Platt, F. W., & Gordon, G. H. (2004). Field guide to the difficult patient interview. Lippincott Williams & Wilkins. Retrieved from

Thiago, V. J., Lima Sousa, A. L., Thais Inacio, R. P., Weimar Kunz, S. B., Chinem, B., Jardim, L., . . . Paulo Cesar Brandao, V. J. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Public Health, 15 Retrieved from

Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal, 91(1079), 508. doi:

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