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Holistic Patient Intake Form and Nursing Resource Handout
Holistic Patient Intake Form and Nursing Resource Handout
Holistic Philosophical, Theoretical, and Ethical Principles
Holistic nursing is a method of patient care that includes treating and healing the entire
person. Nursing theorist Florence Nightingale understood the vital needs of humans and all
aspects of the environment that can affect one's well-being clean air, water, food, houses.
Nightingale's devotion to caring for individuals who cannot care for themselves is a crucial
perspective. Nightingales' environmental theory is still relevant and practiced to this day.
Ethically nurses have the responsibility to provide high quality, safe, and competent care to all
patients. Ethically nurses must respect and empower patient autonomy, allowing and enabling
patients to make their own health decisions.
Integrative nutrition focuses on the relationship of food with a focus on improving health
(Shea et al., 2021). Integrative nutrition is an individualized, tailored diet plan that takes many
factors into consideration (Shea et al., 2021). Integrative nutrition is the foundation of holistic
practice as it considers internal and external factors when assessing persons for a suitable
intervention (Shea et al., 2021). Recommendations are customized for each person's unique
lifestyle and health needs as there are many factors that influence disease environmental,
genetics, physiological, and psychological (Shea et al., 2021). Integrative dietitians merge
training in medical nutrition therapies to integrate causes for imbalances in overall health.
Holistic Caring Strategy for Daily Practice
There are many holistic caring strategies that nurses can incorporate in their daily
practice to improve and promote a healthy psychological, emotional and spiritual environment.
Nurses can educate patients suffering from pain, meditation, and relaxation techniques to avoid
pharmacological methods of pain control. Encourage patients to participate in holistic treatment
plans, and explain the benefits of a massage, aromatherapy, or music therapy. The nurse can
incorporate using therapeutic touch, referred to as an energy therapy.
Therapeutic Communication Strategy
Therapeutic communication in relationship-centered, holistic nursing care is a way of
conveying vital information to a patient that generates trust and inclusiveness. Therapeutic
communication strategies nurses can use in their daily practice are to introduce yourself to the
patient, making eye contact when talking with the patient. Make an attempt to learn the patient's
name or what they prefer to be called. Show compassion by asking the patient how they are
feeling. Ask the patient how you can reduce their anxiety or pain, and use therapeutic touch to
comfort the patient.
Creating Evidence-Based Integrative, Holistic, Caring Environment
Integrative, holistic, caring environments promote therapeutic partnerships and are
associated with alternative/complementary modalities (Frisch & Rabinowitsch, 2019). The focus
is on assessing and addressing the whole patient, physically, spiritually, and emotionally in a
calm healing environment (Frisch & Rabinowitsch, 2019). Nurses have a significant role as
health professionals in creating a healing environment for their patients (Frisch & Rabinowitsch,
2019). Studies show that being close to nature provides positive, healing energy for patients and
Self-Reflective Practice Influences an Individual's Self-Care and Professional Practice.
Self-Reflective practices like reflective journaling are the act of documenting what you
are thinking and experiencing at that moment. Reflective journaling is a technique used to
document, retain, recall, and reassess encounters through reflective writing. Reflective journaling
inspires critical thinking, which is a critical element to delivering safe, quality care (Naber &
Markley, 2017). Recording various scenarios and issues will help one discover techniques when
encountering similar scenarios. Revitalizes nurses' compassion and reduces burnout and
compassion fatigue (Raterink, 2016). Reflective practices increase awareness of emotional
responses and promote professional growth (Naber & Markley, 2017). By keeping a log of ideas,
rationales, procedures, methods, and assessments, one can strategize for your future scenarios
and facilitate positive outcomes.
Holistic Patient Intake Form
Age: ___________________________ Marital Status: _______ Ethnicity: _________
City: ________________ State: ____________________ Zip Code: _______________
Phone Number: ________________________ Emergency Contact: ________________
Email Address: __________________________________________________________
1. How many times a day do you eat including snacks? _________________
2. Do you eat more under stress or feeling depressed? __________________
3. How often do you have a bowel movement? _______________________
Check the box
Mod. Heavy Comments
➢ Please List all current Medications:
1. Please prioritize your most important health concern today:
2. How would you rate your?
Day to day energy level?
Capacity to exercise?
Respond to each question with a number from 0 to 4.
0 = No/Never/Hardly ever 1 = Seldom 2 = Occasionally 3 = Frequently 4 =
Do you feel joy, hope and happiness more often than sadness, despair, and envy? __
Are you able to fully accept, feeling and experiencing painful emotions such as fear,
anger, sadness, and misery? ___
Are you able to express your true emotions including safely and comfortably allowing
yourself to cry? ___
Do you comfort yourself when you are upset? ___
Do you experience feelings of exhilaration or enjoyment? ___
Are you generally free of shame or guilt about your past? __
Has shame or guilt led to productive self-reflection? ___
Has an experience of pain or suffering allowed you to grow personally or spiritually? ___
If you have experienced the loss of a loved one, have you fully grieved that loss? ___
Do you feel victimized by old trauma? ___
Are you harboring anger toward your victimizers and enemies? ___
Is your sleep free from disturbing dreams? ___
Do you speak openly with one or more close friends? ___
Do you have a romantic partner? ___
Do you have a support system of family and friends to help you in times of need? ___
Do you go out of your way or give time to help others? ___
Do you take a day of rest completely away from work, dedicated to nurturing yourself
and your family?
How often do you forget things?
Is it hard to maintain a lasting relationship?
Are you generally satisfied with your life?
How often are your personal goals that you
set are met?
Do you have spiritual beliefs that help you cope with stress?
What gives your life meaning?
Are you part of a spiritual or religious community?
What aspects of your spirituality or spiritual practices are most helpful?
Have your beliefs influenced how you take care of yourself in this illness?
Do you feel discrimination or based on your race, sex, or creed?
Are there any medical conditions that you feel is labeled negatively by our culture?
If yes, please describe?
Are there any cultural beliefs that will influence you care?
Who is considered part of your family?
What is your role in the family?
How old are the family members that are helping with your care?
Are there physical restrictions that would prevent a family member from caring
What is the history of environmental concerns in your community?
What is the quality of the air, the water, and the green space?
Do you see a link between health problems and your environment?
Have traditions in your community changed because of environmental issues?
Has there been community support for focusing on the environmental
Do you understand all instructions giving by your doctor?
Are you taking your medication as prescribed?
Is it hard for you to stay on task with your healthcare?
There are many areas in healthcare education. Are there any
areas where you think you need more information?
Are there times where you feel hopeless with your health?
Are you or have you felt so depressed it was preventing you from living your life?
Do you have problems in your life that make you feel like it won’t get better?
Do you have thoughts of suicide? If so, please give details?
There is information about support groups and resources for mental health if you
would like it?
Within your community is their access to the healthcare that you need?
Does your community meet your needs regarding resources specific to you?
Are there any changes you would makes within your community? If so, what are
Do you want to see positive changes in your community? What are they?
Patient Treatment Plan
How would you want your treatment to be?
Would you prefer a conventional method to your healthcare?
What are the negative side effects, or have you had any negative side
effects to any medication?
What are the other treatments or therapies you tried and liked?
Are there any natural therapy/treatments you tried?
Would you try a holistic approach to your therapy/treatment?
Would you like more information on Complementary Treatment?
List your health goals in one year?
List your health goals in five years?
Your ideal health looks like what for
Are there any problems you see that
would keep you from accomplishing
your health goals?
Frisch, N., & Rabinowitsch, D. (2019). What’s in a definition?holistic nursing, integrative health
care, andintegrative nursing: Report of an integrated literature review. Journal of Holistic
Nursing, 37(3), 260–272. https://doi.org/10.1177/0898010119860685
Naber, J., & Markley, L. (2017). A guide to nursing students' written reflections for students and
educators. Nurse Education in Practice, 25, 1–4.
Raterink, G. (2016). Reflective journaling for critical thinking development in advanced practice
registered nurse students. Journal of Nursing Education, 55(2), 101–104.
Shea, A., Brophy, L., Nininger, J., Abbott, M., & Wilson, L. (2021). Nutrition integration across
the nursing curriculum: A novel teaching model within a pre-licensure program. Journal
of Professional Nursing, 37(6), 1162–1166.