4.5: Appendix B - The Complete Subjective Health Assessment - Interview Guide

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Introductory Information: Demographic and Biographic Data

Name/contact information and emergency information

What is your full name?
What name do you prefer to be called by?
What is your address?
What is your phone number?
Who can we contact in an emergency? What is their relationship to you? What number can we reach them at?

Birthdate and age

What is your birthdate?
What is your age?

Gender

Tell me what gender you identify with.
What gender pronouns do you use? (If the person asks you to use a pronoun that you are not familiar with, it is okay for you to respectfully respond, “I am not familiar with that pronoun. Can you tell me more about it?”)

Allergies

Do you have any allergies?
If so, what are you allergic to?
How do you react to the allergy?
What do you do to prevent or treat the allergy?

Note: You may need to prompt for information on medications, foods, etc.

Languages spoken and preferred language

What languages do you speak?
What language do you prefer to communicate in (verbally and written)?

Note: You may need to inquire and document if the client requires an interpreter.

Relationship status

Tell me about your relationship status?

Occupation/school status

What is your occupation? Where do you work?
Do you go to school?

Resuscitation status

We ask all clients about their resuscitation status, which refers to medical interventions that are used or not used in the case of an emergency (such as if your heart or breathing stops). You may need more time to think about this, and you may want to speak with someone you trust like a family member or friend. You should also know that you can change your mind. At this point, if any of this happens, would you like us to intervene?

Main Health Needs (Reasons for Seeking Care)

Presenting to a clinic or a hospital emergency or urgent care (first point of contact)

Tell me about what brought you here today.

Probes

Tell me more.
How is that affecting you?

Already admitted, and you are starting your shift

Tell me about your main health concerns today.

Probes

Tell me more.
How is that affecting you?

The PQRSTU Mnemonic

Provocative

What makes your pain worse?

Palliative

What makes your pain feel better?

Quality

What does the pain feel like?

Quantity

How bad is your pain?

Region

Where do you feel the pain?
Point to where you feel the pain.

Radiation

Does the pain move around?
Do you feel the pain elsewhere?

Severity

How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you’ve ever experienced?

Timing

When did the pain start?
What were you doing when the pain started?
Where were you when the pain started?
Is the pain constant or does it come and go?
If the pain is intermittent, when did it last occur?
How long does the pain last?

Treatment

Have you taken anything to help relieve the pain?
Have you tried any treatments at home for the pain?

Understanding

What do you think is causing the pain?

Current and Past Health

Current health

Are there any other issues affecting your current health?

Childhood illnesses

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 hospitalized? Where? How was it treated?
Who was the treating practitioner?
Did you experience any complications?
Did it result in a disability?

Chronic illnesses

Tell me about any chronic illnesses you currently have or have had (e.g., cancer, cardiac, hypertension, diabetes, respiratory, arthritis).

Probes

How has the illness affected you?
How do you cope with the illness?
When were you diagnosed?
Who was the treating practitioner?
How was the illness being treated?
Have you been hospitalized? Where?
Have you experienced any complications?
Has the illness resulted in a disability?
How does the illness affect your day-to-day life?

Acute illnesses, accidents, or injuries

Tell me about any acute illnesses that you have had.
Tell me about any accidents or injuries you currently have or have had.

Probes

When did it occur?
Were you hospitalized? Where?
How was it treated?
Who was the treating practitioner?
Did you experience any complications?
Has it resulted in a disability?
How did it affect your day-to-day life?

Obstetrical health

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?

Mental Health and Mental Illnesses

Mental health is an important part of our lives and so I ask all clients about their mental health and any concerns or illnesses they may have.

Mental health

Tell me about your mental health.
Tell me about the stress in your life.
How does stress affect you?
How do you cope with this stress? (this may include positive or negative coping strategies.)
Have you experienced a loss in your life or a death that is meaningful to you?
Have you had a recent breakup or divorce?
Have you recently lost your job or been off work?
Have you recently had any legal issues?
Have you purchased any weapons?

Mental illness

How does that illness affect you?
How does that illness affect your day-to-day life?
How do you cope with the illness?
What resources do you draw upon to cope with your illness?
When were you diagnosed?
Who was the treating practitioner?
Have you been hospitalized? Where?
Tell me about your treatment (e.g., medications, counselling).
Have you experienced any complications?
Has the illness resulted in a disability?
Do you have any concerns that have not been addressed related to your illness?

Functional Health

Nutrition

Tell me about your diet.
What foods do you eat?
What fluids do you drink? (Probe about caffeinated beverages, pop, and energy drinks.)
What have you consumed in the last 24 hours? Is this typical of your usual eating pattern?
Do you purchase and prepare your own meals?
Tell me about your appetite. Have you had any changes in your appetite?
Do you have any goals related to your nutrition?
Do you have the financial capacity to purchase the foods you want to eat?
Do you have the knowledge and time to prepare the meals you want to eat?

Elimination

How often do you urinate each day?
What colour is it (amber, clear, dark)?
Have you noticed a strong odour?
How often do you have a bowel movement?
What colour is it (brown, black, grey)?
Is it hard or soft?
Do you have any problems with constipation or diarrhea? If so, how do you treat it?
Do you take laxatives or stool softeners?

Sleep and rest

Tell me about your sleep routine.

Probes

How much do you sleep?
Do you wake up at all?
Do you feel rested when you wake? What do you do before you go to bed (e.g., use the phone, watch TV, read)?
Do you take any sleep aids?
Do you have any rests during the day?

Mobility, activity, exercise

Tell me about your ability to move around.
Do you have any problems sitting up, standing up or walking?
Do you use any mobility aids (e.g., cane, walker, wheelchair)?
Tell me about the activity and/or exercise that you engage in. What type? How frequent? For how long?

Violence and trauma

Many clients experience violence or trauma in their lives. Can you tell me about any violence or trauma in your life?
How has it affected you?
Tell me about the ways you have coped with it.
Have you ever talked with anyone about it before?
Would you like to talk with someone?

Relationships and resources

Tell me about the most influential relationships in your life.
Tell me about the relationships you have with your family.
Tell me about the relationships you have with your friends.
Tell me about the relationships you have with any other people.

Probes

How do these relationships influence your day-to-day life? Your health and illness?
Who are the people that you talk to when you require support or are struggling in your life?

Intimate and sexual relationships

I always ask clients about their intimate and sexual relationships. To start, tell me about what you think is important for me to know about your intimate and sexual relationships.
Tell me about the ways that you ensure your safety when engaging in intimate and sexual practices.
Do you have any concerns about your safety?

Substance use and abuse

To better understand a client’s overall health, I ask everyone about substance use such as tobacco, herbal shisha, alcohol, cannabis, and illegal drugs.
Do you or have you ever used any tobacco products (e.g., cigarettes, pipes, vaporizers, hookah)? If so, how much?
When did you first start? If you used to use, when did you quit?
Do you drink alcohol or have you ever? If so, how often do you drink?
How many drinks do you have when you drink?
When did you first start drinking? If you used to drink, when did you quit?
Do you use or have you used any cannabis products? If so, how do you use them? How often do you use them?
When did you first start using them?
Do you purchase them from a regulated or unregulated place?
If you used to use cannabis, when did you quit?
Do you use any illegal drugs? If so, what type? How often do you use them?
Tell me about the ways that you ensure your safety when using any of these substances.
Have you ever felt you had a problem with any of these substances?
Do you want to quit any of these substances?
Have you ever tried to quit?

Environmental health and home/occupational/school health

Tell me about any factors in your environment that may affect your health. Do you have any concerns about how your environment is affecting your health?
Tell me about your home. Do you have any concerns about safety in your home or neighbourhood?
Tell me about your workplace and/or school environment.
What activities are you involved in or what does your day look like?

Self-concept and self-esteem

Tell me what makes you who you are.
Are you satisfied about where you are in your life?
Can you share with me your life goals?

Probes

Tell me more.
Please explain.

Other iADL

Tell me about how you take care of yourself and manage your home.
Do you have sufficient finances to pay your bills and purchase food, medications, and other needed items?
Do you have any current or future concerns about being able to function independently?

Preventive Treatments and Examinations

Medications

Do you have the most current list of your medications?
Do you have your medications with you? (If not, you should ask them to list each medication they are prescribed and if they know, the dose and frequency.)
Can you tell me why you take this medication?
How long have you been taking this medication?
Do you take the medications as prescribed? (If they answer “no” or “sometimes,” ask them to tell you the reasons for not taking the medications as prescribed.)

Examination and diagnostic dates

When was the last time you saw [name the primary care provider, nurse or specialist]?
Can you share with me why you saw them?
When was the last time you had your [name screening] tested?
Do you know what the results were?

Vaccinations

Can you tell me about your immunization status?
Can you tell me what immunizations you have had, the dates you received them, and any significant reactions?
Do you have your immunization record?
When was your last flu vaccine?

If the client’s immunizations are not up-to-date or you noted vaccination hesitancy, you may ask:

Can you tell me the reasons that your immunizations are not up-to-date?
Can you tell me why you are hesitant to receive immunizations. (You may need to explore this further.)

Family Health

Tell me about the health of your blood relatives.
- Do they have any chronic or acute diseases (e.g., cardiac, cancer, mental health issues)?
Have any of your blood relatives died?
- If so, do you know the cause of death?
- And at what age did they die?
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

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?

Probes:

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?