CLIENT BIOGRAPHICAL INFORMATION

A. Full name
B. Address and telephone numbers telephone Number
1. Client's permanent
2. Contact of Client
C. Birthdate
D. Sex
E. Race
F. Religion
G. Marital Status
H. Occupation
I. Birthplace
J. Source of referral
K. Usual Source of Health Care
L. Source and and reliability of information
M. Date of Interview

First, Record the client's name. Since persons who live in an ethnically homogenous geographical area of¬ten have similar names, it is important that this key information be exact. Precise identification, including firs, middle, and last names, assists in ensuring accurate information retrieval and coordination. If additional identifying information is needed, record the parents' name, including the mother's maiden name.
Next, record the client's full mailing address and tele¬phone numbers. Also include the name, address, and telephone number of one of the client's friends or rel¬atives. This person should be someone with whom tile client is in frequent contact and who would be willing anti able to relay a message to the client in all emergency or if the client cannot be located.
The birthdate sex, race, religion, marital status, and birthplace entries are self-explanatory. Many health problems and needs are related to age, sex, race, or social situation. This information provides initial insight into the client as a unique person and can be correlated with the client's needs and problems discovered later in the history.
Justifiable reasons for recording the client's Social Security number include the precise identification of each client and potential access to a large pool of health related information. The potential for violation of client confidentiality is a disadvantage.
A significant difference may exist between the client's current and usual occupations. The nature of the dif¬ference may indicate the severity of the client's health problems and the level of disability resulting from them
in addition, knowledge of past occupations might pro¬vide clues to past or present environmental hazards contributing to the present illness. A mine worker with a respiratory system complaint is an example.
Knowledge of the client's birthplace provides geo¬graphical information associated with the origin of problems and cultural implications for therapy and health maintenance.
If the current caregivcr is not tile usual anti primary source of the client's care, record the name and address of tile individual or institution so identified by the client. In addition, document tile reason that tile client is en¬tering a new health care system. The client may be in crisis, may be dissatisfied with past care, or may be .shopping. If the past source of care possesses signif¬icant data about the client's health and if the client intends to continue in tile current health care system, ask the client to sign a permission for the transfer of information. Later in the health history, you will have the opportunity to record, in sonic detail, past patterns of health care
The source of client payment for care is usually included on administrative record. However, nothing this information in the health history might be useful in guiding choice of interventions, next , make a statement about the source of the information to follow. In most instances the source is the client, but do not assume that this is so unless the source is specifically identified. If the information is given by some one other then the client, describe the nature of the informant's contact with the client. For example. In the case of the child, a history given by grandmother who resides with child should be viewed differently from one given by a grandmother who visit the child the child once a week