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How to Do a Health Assessment

A health assessment is a judgment of physical, mental and quality standards of a person’s life. It is most often conducted by a medical office and it is often given to elderly people. A health assessment may also be done by insurance companies or employers, looking to review an employee’s overall health. Each medical institution uses its own scoring and scale of good health. You will want to judge both the appearance of health, the need of assistance and the person’s pain or feeling during the activity. You should decide upon the difficulty and pain scale before performing the health assessment. For example, some people use words to describe pain while other people use a scale of between 1 and 10, with 10 being the worst. This article will tell you how to do a health assessment.

Ask the person to complete a questionnaire that lists any symptoms that they have experienced in the last week to 6 months, as defined by your facility. This should be a standard questionnaire that requires a patient to check certain boxes and allows the person space to write recent procedures.

  • These symptoms should include musculoskeletal, ears, nose, throat, head, chest, lungs, heart, neurological, psychological, gastrointestinal and dermatological.

Ask the person to list their current medications. Then, ask your patient to rate their general pain on a scale that you have decided upon. This will mean more in a medical, than an employment, test.

Perform a physical examination of the person if you are a doctor. This can include a blood test for cholesterol, insulin and blood cell levels, or a pap smear if you are a woman. Also, take the height, weight, pulse and other measurements as required of a yearly physical examination.

  • Test the vision, hearing, chest and lungs of the person with medical instruments. You will need a stethoscope and other instruments to ensure these functions are accurate. Only a doctor should perform these elements of the physical health assessment.

Test the mobility of the person in question. Test their walking ability by checking if they are able to walk unassisted from room to room. Note any problems with walking and ask the person if this causes pain on a scale of your choosing.

  • Follow the walking test with a walking test up and down a small flight of stairs. Ask the person if this causes pain on a scale of your choosing.
  • See if the person is able to walk unassisted outside a household. Ask if they are able to perform the tasks needed to get ready to leave the house and walk on uneven ground. They may or may not need assistive technology, such as a cane or a walker.

Test the balance of the person. You can do this in a number of ways. The most common ways are asking the person to stand on 1 foot (0.3 m) for 30 seconds and then the other, and to ask them to walk on their toes and then on their heels.

Ask if medical illness or depression has left them with an inability to shop or provide meals for themselves. This will not be essential in all cases, and it may need to be done with some delicacy.

  • You may choose to take the person’s Body Mass Index (BMI), which is the person’s weight in kg divided by the square of their weight in m. If the person has lost 10 lbs. (4.5 kg) since a recent visit, it may also be seen as a problem with nutrition.

Ask if the person is able to bathe daily, dress, go to the bathroom by themselves and groom daily. These questions are essential amongst those in the elderly age bracket and should be rated on a scale of difficulty.

  • You may choose either a scale of numbers or words, such as “with no difficulty,” “with some difficulty” and “with great difficulty.”

Identify if the person is able to take care of their household affairs, or Activities of Daily Living (ADL). The following are household affairs that the person should rate the difficulty of completing, and if they are not properly able to complete them, a caretaker should be notified.

  • Doing the laundry and washing the dishes and doing other household cleaning and chores.
  • Managing household finances, from grocery and electric bills to taxes.
  • Taking medications as directed by a doctor, as well as arranging for transportation to all appointments and/or work.

Ask the person if they are experiencing any symptoms of anxiety or depression.Although they may have filled out this information in their questionnaire, you may be able to bring to light feelings of loss, low self-esteem, lower functionality in daily life or other symptoms.

Perform a memory test, such as the Folstein Mini-Mental State Examination (MMSE). This may be a series of tests designed to detect dementia or delirium. Any mental health tests should be well-established as viable ways to detect memory loss or loss of mental function.

Test the person’s executive function. This is the ability of the person to respond to new stimuli or a change in plans. One of the easiest ways to test this function is to ask the person to name as many 4-legged animals as they can in 1 minute.

  • Being able to list fewer than 8 animals or repeating animals is seen as a call for further memory testing.

Ask the person to explain their social network, including any friends or family that give support. You should discuss the financial needs for support by any government agencies and discuss the need for a caregiver.

Gather all of the information that was given through the tests and rate it on the agreed upon health scale. Not all aspects of this test may be essential for your health assessment. It is important that you agree upon a plan to see the person for a follow up, whether it is a doctor’s appointment in a year, an insurance quote or a plan to see a specialist or caregiver.