Chamberlain College of Nursing NR305 Health Assessment
Course Project Milestone #1: Health History Form
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Directions : Refer to the Milestone 1: Health History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 175 points, with 5 points awarded for clarity of writing, which means the use of proper grammar, spelling, and medical language.
Type your answers on this form. Click “Save as” and save the file with the assignment name and your last name, e.g., “NR305_Milestone1_Form_Smith”. When you are finished, submit the form to the Milestone #1 Dropbox by the deadline indicated in your guidelines. Post questions in the Q & A Forum or contact your instructor if you have questions about this assignment.
Disclaimer : The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.”
| BIOGRAPHICAL DATA (10 pts) | |
| Date: | 5/22/16 |
| Initials: | LM |
| Age: | 45 years old |
| Date of birth: | 4/10/1971 |
| Birthplace: | Puerto Rico |
| Gender: | Female |
| Marital status: | Married |
| Race: | Hispanic, Latino |
| Religion: | Baptist |
| Occupation: | Head Manager of Accounting Department |
| Health insurance: | Does not want to disclose |
| Source of information: | Patient herself |
| Reliability of source of information: | Patient seems reliable, keeps answering the same questions without changing the previous answer. |
| PRESENT HEALTH HISTORY/ILLNESS (15 pts) | |
| Reason for seeking care: | “ Started feeling left arm,shoulder numbness today at work, my blood sugar was elevated” |
| Health patterns: | Does not want to disclose |
| Health goals: | HA1c bellow 6 , lose 30 pounds, |
| HEALTH BELIEFS AND PRACTICES (15 pts) | |
| Beliefs and practices: | Patient does not follow a healthy diabetic diet |
| Factors influencing healthcare decisions: | Stress at work,long working hours without eating a proper diet, depression, low self-esteem, mother of five children . Going to school for her Master Degree. |
| Related traits, habits or acts: | Obesity, feels overwhelmed, eats fast food everyday |
| MEDICATIONS (15 pts) (Please refer to your assignment guidelines.) | |
| Prescription medications: | Metformin 500mg BID
Aspirin 325mg Daily Zocor 10mg Daily |
| Over-the-counter medications: | Tylenol |
| Herbals: | Melatonin |
| PAST HISTORY (15 pts) | |
| Childhood diseases: | Varicella, Chicken pox |
| Immunizations: | Does not remember |
| Allergies: | NKA |
| Blood transfusions: | One 10 years ago |
| Major illnesses: | Diabetes type 2 |
| Injuries: | Car accident two weeks ago, no major injury. |
| Hospitalizations: | First time |
| Labor and deliveries: | Grav 5, Term 3, Preterm 2, Ab 0, Living 5 |
| Surgeries: | Appendectomy, 2 C-sections |
| Use of alcohol: | Occasionally |
| Use of tobacco: | Denies |
| Use of illicit drugs: | Denies |
| EMOTIONAL HISTORY (15 pts) | |
| Mental, emotional or psychiatric problems: | Depression |
| FAMILY HISTORY (15 pts) | |
| Father: | Tobacco smoker, died from stroke 3 years ago |
| Mother: | Diabetes type 2 |
| Siblings: | Cancer, Diabetes, Hypothyroidism |
| Grandparents: | Alzheimer, MI, Suicide |
| PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts) | |
| Occupational history: | Sales Representative, Accounting , |
| Educational level: | Associated Degree |
| Financial background: | Employee |
| ROLES AND RELATIONSHIPS (15 pts) | |
| Significant others: | Husband |
| Support systems: | Family |
| ETHNICITY AND CULTURE (10 pts) | |
| Ethnicity and culture: | Music, Art, Dance, Traditions |
| Physical and social characteristics that influence healthcare decisions: | Sedentary lifestyle , Obesity |
| SPIRITUALITY (5 pts) | |
| Religious and spiritual needs: | Improve self-esteem . |
| SELF-CONCEPT (5 pts) | |
| View of self-worth: | She does not feel good about the way she physically looks |
| Future plans: | Exercise, get more information on Diabetes management and diet, lose weight. |
| REVIEW OF SYSTEMS (20 pts) (Please refer to your assignment guidelines and chapter 4 of your text. This is NOT a physical assessment.) | |
| Skin, hair, nails: | Normal for ethnicity, warm, brittleness nails |
| Head, neck, related lymphatics: | Frequent headaches, dizziness |
| Eyes: | Decreased vision , wear glasses |
| Ears, nose, mouth, and throat: | Increase Thirst |
| Respiratory: | Denies cough, chest pain or shortness of breath |
| Breasts and axillae: | Pain to the back due to breast are too big. |
| Cardiovascular: | Dyspnea at night , Anemia |
| Peripheral vascular: | Swelling of legs at night after working for long hours |
| Abdomen: | Abdominal pain, constipation |
| Urinary: | Awakens up to 3 times to urinate at night |
| Reproductive: | Last menstrual period 4/13/16 |
| Musculoskeletal: | Generalized weakness, back pain |
| Neurologic: | Left arm numbness |
Milestone 1: Health History Form Rev. 10/29/14jm 2
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