When performing comprehensive health assessments, it is best to use a consistent approach, although there is no one correct order in which the assessment must be performed. However, by adhering to a predetermined and consistent sequence, the examiner is less likely to omit an important measure. For example, when gathering a sociocultural history, you can develop your own routine to ensure accuracy.

When taking a socioculural history, it’s important to obtain information on the patient’s living/work environment, activity patterns, rest and sleep patterns, economic status, recreational interests, social patterns, diet, use of substances such as drugs, alcohol, and tobacco, coping mechanisms, and patterns of health seeking.

A look at these key factors will help you gather the necessary information in a logical order:

• Ethnicity/Culture. Place of birth, primary language, and religion help to determine cultural variations that should be considered in any healthcare provision.
• Occupational. Look at any unplanned changes in occupational and/or economic status; exposures to hazardous substances or equipment; and degree of protection.
• Recreational. Pay attention to the presence/absence of recreational interests and potentially dangerous recreational activities, including contact or extreme sports.
• Substance use. Look at any use of tobacco, alcohol, and prescribed OTC or illicit drugs. Also, be aware of the frequency, amounts, and routes of using each.
• Relationships. Be wary of the presence/absence of close relationships, any abusive situations, the degree of satisfactions with sexual relationships, and any risks associated with unprotected sex.
• Diet. Pay attention to the adequacy of caloric and nutrient intake, any excesses, caffeine intake, and the ability to obtain, afford, and prepare groceries.
• Coping. Look at the means used to cope with stressors and any unresolved angers.

Editor’s note: This excerpt was adapted from HCPro’s Quick E! Assessment. Click on the Quick E! link at the top right of this page to learn more about all 10 titles in the clinical reference guide series.