Application Of A Health Promotion Assessment

Denver College of Nursing

NUR 335 Practicum Assignment 5.1

Health Promotion Assessment Worksheet

A health promotion assessment is a targeted assessment where the nurse assesses for health risks and education gaps that can be improved through health promotion interventions

Use this worksheet to interview an individual. There is a section at the bottom for you to add additional assessment information. Document your findings on the worksheet


Initials: ________________


Sex: ___________________

Primary Language Spoken: _______________

Cultural Background:____________________


General Health

How would you rate your general health?

Have you had a wellness checkup with a healthcare provider in the past year?

Have you ever been told by a health care provider that you have a chronic disease such as hypertension, diabetes, heart disease, stroke, arthritis or kidney disease?

In the past month, have you had pain on more than three days that impacted your ability to perform your normal daily activities?

If yes:

· Where was the pain located?

· What have you tried to relieve the pain?

How would you rate the quality of your sleep?

· How many hours do you regularly sleep in a night?

· Do you ever wake up before you wanted to?, you have problems falling asleep?


Are you currently taking medicine for any chronic condition?

· Do you know what the medication is used to treat?

· Have you missed doses of your medication in the last week?

Women Only:

Are you pregnant or planning on becoming pregnant in the next year?

A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?

· If yes, when was your last mammogram?

A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?

· If yes, when was your last Pap test?

Men Only:

A PSA test is a test for cancer of the prostate. Have you ever had a PSA test?

· If yes, when was your last PSA test?


Do you now smoke cigarettes every day, some days or not at all?

· If you are currently smoking, have you tried to quit?

· If yes, what methods have you used to quit smoking?, Were the methods successful?

For the questions below consider the past week in your answer: