assigmnent 10

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Complete Health History and Examination Assignment

NUR3069- Advanced Health Assessment

Miami Dade College- Medical Campus

I. Biographical data:

Name (Initials only): _______________________________________ Age: _______________

Gender: M or F Birthplace: _______________________________________ (City/Country)

Marital Status: ____________________ Occupation: ________________________________

Race/ ethnic origin: _____________________ Employer: ______________________________

Accompanied by, or, significant other: ______________________________________________

Source and reliability of information: _______________________________________________

Source of referral: _____________________________

Reason for seeking care: _________________________________________________________

Present health or HPI (if applicable): _______________________________________________

Present Illness (if applicable): __________________________________

Time of onset: ____________________________ Type of onset: ________________________

Severity: ______________________________ Radiation: ______________________________

Time Relationship: _______________________ Duration: _____________________________

Course: _____________________________ Association: ______________________________

Source of relief: _______________________ Source of aggravation: _____________________

II. Past Medical History (PMH):

General State of Health: ______________________________

Childhood Illnesses: ____________________________________________________________

_____________________________________________________________________________

Childhood Vaccinations: ________________________________________________________

____________________________________________________________________________

Adult Illnesses: _______________________________________________________________

____________________________________________________________________________

Past Surgeries: ________________________________________________________________

_____________________________________________________________________________

Past Hospitalizations:___________________________________________________________

____________________________________________________________________________

Psychiatric Disorders Diagnosed: _________________________________________________

_____________________________________________________________________________

III. Current Health Status:

Current Medications: (OTC, PRN’s and Prescribed) ___________________________________

______________________________________________________________________________

Allergies: (Food, Meds or Environment) _____________________________________________

______________________________________________________________________________

Drugs: ________________________________________________________________________

Alcohol: ______________________________________________________________________

Tobacco: ______________________________________________________________________

Diet: (24-hour totals) ____________________________________________________________

______________________________________________________________________________

Screening tests: ________________________________________________________________

Sleep patterns: _________________________________________________________________

Exercise & Leisure activities: ____________________________________________________

Environmental hazards: _________________________________________________________

Safety measures: ______________________________________________________________

IV. Family History:

Known genetic problems: _______________________________________________________

____________________________________________________________________________

Heart disease: _____________________ Allergies: ____________________

Hypertension: ____________________ Asthma: ____________________

Stroke: _____________________ Obesity: ________________

Diabetes: ____________________ Alcoholism: ________________

Blood disorders: ________________ Mental illness: ________________

Breast cancer: __________________ Kidney disease: _______________

Cancer (other): __________________ Seizure disorder: _______________

Sickle Cell: ___________________ Arthritis: __________________

V. Genogram: (Attached)

VI. Review of Systems: (3 negatives needed)

General: ____________________________________________________________________

Skin: ______________________________________________________________________

Neurological: ________________________________________________________________

Eyes: _______________________________________________________________________

Ears: _______________________________________________________________________

Nose/Sinuses: _________________________________________________________________

Mouth/Throat: ________________________________________________________________

Neck: _______________________________________________________________________

Respiratory: __________________________________________________________________

Chest/Breast: _________________________________________________________________

Cardiac: _____________________________________________________________________

Gastrointestinal: _______________________________________________________________

Genitourinary: _________________________________________________________________

Peripheral vascular: _____________________________________________________________

Musculoskeletal: _______________________________________________________________

Hematological: ________________________________________________________________

Endocrine: ___________________________________________________________________

Psychiatric: ___________________________________________________________________

Physical Examination:

Vital Signs:

Temperature (F°): _____________ (Oral/tympanic/rectal) Pulse: __________________ (artery?)

Resp Rate _________________ Weight: ________________ Height: ________________

BMI: ______________ Physical appearance: ________________

Level of Consciousness: ___________________ Facial features: ____________________