health assessment

Comprehensive History and Patient Examination

Patient Name: ______________________________________________________________________ Age: ________ Sex: __________ Race: _________

Subjective Data Collection: Describe client chief complaint (C/C) in narrative format. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Past Medical History: Allergies______________________________________________________________________________

Medications: __________________________________________________________________________

Medical: _____________________________________________________________________________

Surgical: _____________________________________________________________________________

Health Maintenance: Last physical: ________________________________________________________

Immunizations and Date if known: _____________________________________________________________________________________

Recent travel or Military service: __________________________________________________________

Family Health History: _____________________________________________________________________________________Psychiatric Health History: _____________________________________________________________________________________

Nutritional Health History: _______________________________________________________________

Personal Habits: {Sleep patterns, health practices, Tobacco, Alcohol, Drugs, cultural/religious influences}____________________________________________________________________________

Review of systems (Subjective data):

HEENT: ______________________________________________________________________________

Cardiovascular: ________________________________________________________________________

Respiratory: ___________________________________________________________________________

Gastrointestinal: _______________________________________________________________________

Genitourinary: _________________________________________________________________________

Musculoskeletal: _______________________________________________________________________

Integumentary: ________________________________________________________________________

Neurological: __________________________________________________________________________

Endocrine:____________________________________________________________________________

Hematologic/Lymphatic:________________________________________________________________

Immunological:________________________________________________________________________

Female/Male Reproductive Organs: {Breast, Scrotal, Rectal, Vaginal}:

_____________________________________________________________________________________

_____________________________________________________________________________________

Physical Assessment (Objective data):

LOC: ______________________Appearance: ________________________ Speech: _______________

Clinical Findings: Describe patient assessment in narrative format.

Skin, Hair, Nails: __________________________________________________________________________________________________________________________________________________________________________

HEENT: _________________________________________________________________________________________________________________________________________________________________________

Respiratory system: __________________________________________________________________________________________________________________________________________________________________________

Cardiovascular system: __________________________________________________________________________________________________________________________________________________________________________Gastrointestinal system: __________________________________________________________________________________________________________________________________________________________________________

Genitourinary: __________________________________________________________________________________________________________________________________________________________________________

Musculoskeletal system: __________________________________________________________________________________________________________________________________________________________________________

Neurological system: __________________________________________________________________________________________________________________________________________________________________________

Functional Assessment: __________________________________________________________________________________________________________________________________________________________________________

ASSESSMENT: (problem list)

Example: Small circular wound to left lower leg.

1___________________________________________________________________________________

2.___________________________________________________________________________________ 3.___________________________________________________________________________________ 4.___________________________________________________________________________________5.___________________________________________________________________________________

PLAN: (Risk for each problem on the problem list and nursing recommendations for each problem)

Example: Client is at risk for infection with leg wound. Plan is to have client keep wound clean and bandaged.

1.___________________________________________________________________________________ ____________________________________________________________________________________ 2.__________________________________________________________________________________

_____________________________________________________________________________________3.________________________________________________________________________________________________________________________________________________________________________ 4.________________________________________________________________________________________________________________________________________________________________________ 5.________________________________________________________________________________________________________________________________________________________________________

Completed by: ________________________________________________________________________

03/27/2023