Chapter 3: The Complete Subjective Health Assessment

Introductory Information: Demographic and Biographic Data

“Introductory information” refers to the demographic and biographic data that you collect from the client. This data provides you with basic characteristics about the client, such as their name, contact information, birthdate and age, gender, gender pronouns, allergies, languages spoken and preferred language, relationship status, occupation, and resuscitation status.

Although this data is brief and succinct, the intent of collecting it is not to be reductionist or to label clients. Rather, it is meant as a brief overview of the client and to provide the information you need to reach next of kin in an emergency, to be attentive to allergies at a glance, and to tend to the client in a caring manner. See Film Clip 1 of a nurse conducting an assessment of a client’s demographic and biographic data. See Table 3 for suggested questions and statements you can use to collect this data in an inclusive and caring manner, as well as an example of a demographic and biographic form below.

 

Film Clip 1: Nurse assessing demographic and biographic data (Keep in mind that is best to just ask “What gender pronouns do you use?” as opposed to using the language “preferred pronouns.” This video was created prior to the shift in language).

Table 3: Introductory information: Collecting demographic and biographic data

Data

Questions and Statements

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.

  • Not everyone uses a gender pronoun, but if you do, 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.

Note: Avoid questions such as “Are you married?” or “Do you have boyfriend?” or “Do you have a wife?” as they assume normative behaviour and heterosexuality.

Occupation/school status

  • What is your occupation? Where do you work?

  • Do you go to school?

Note: Reassure the client that this information provides insight into the nature of their work (e.g., the physical or mental impact) and environmental exposures, and that the question is not intended to evaluate the client.

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?

Note: Depending on the client’s answer, you will need to collaborate with the broader healthcare team, explore the details of the client’s wishes further, and have them complete a requisite resuscitation form.

 

 

Demographic Information Form (Example)

Clicking the hyperlinked question mark (?) next to the example form fields will take you to some suggested questions to ask your patient.

 

Interview Date:                            

Client Name:                                                     (?)

Date of Birth:                            (?)

Age:                            Sex:   Male / Female / Another Option                           

Gender You Self Identify With:                             (?)           Pronouns:                                 

Healthcard Number:                                    

Primary Language:                                       (?)

Relationship Status:                                       (?)

Phone Number:

Address:

 

Allergies:                                       (?)

Occupation/Education:                                       (?)

Resuscitation Status: (?)

 

Emergency Contact:                                            Relationship to Patient:

Phone Number:

Information from:  Patient / Other

Patient Accompanied: Yes / No                          Accompanied’s Details:

 

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