Health History RUA

HEALTH HISTORY

(Note: This is only a health history/patient teaching assignment. DO NOT collect objective data.)

DO NOT ALTER THIS FORM

Patient MUST be older than 21 years of age

Interview must be completed in person or virtually (do NOT do this via phone or email)

BIOGRAPHIC DATA (1 points)

Name (Initials): Age: Gender: Marital Status:

Date of Birth: Birthplace:

Address

Race:

Religion/Culture:

Occupation:

Insurance Coverage:

Source of Information & Reliability:

PRESENT HEALTH OR ILLNESS

Reason for Seeking Care: (“In quotes”) (1 points)

Present Health: (chronological account (background history) of ONE priority male/female health issue/educational opportunity) (3 points)

PAST HISTORY (10 points)

Serious or Chronic Illnesses (asthma, depression, diabetes, hypertension, heart disease, HIV infection, hepatitis, sickle-cell anemia, cancer, seizure disorder; year of diagnosis)

Hospitalizations (year; cause, name of hospital, how the condition was treated, how long the person recovered)

Surgeries (year; type of surgery, date, name of surgeon, name of hospital, how person recovered)

Obstetric History (year; GTPALM; course of each complete pregnancy)

Last Examination Date (physical, dental, vision, hearing, ECG, chest x-ray, mammogram, colonoscopy, serum cholesterol)

Allergies (allergan and reaction)

Current Medications (prescription and OTC; name, dose, schedule)

FAMILY HISTORY (coronary artery disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast/ovarian cancer, colon cancer, sickle-cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, TB) (10 points)

Genogram (3 generations to include parents and grandparents) – May complete on a separate page

REVIEW OF SYSTEMS (30 points)

Instructions: Highlight symptom if present, then complete analysis for each symptom using OLDCART: (O = Onset, L = Location, D = Duration, C = Characteristics, A = Aggravating Factors, R = Relieving Factors, T = Treatment)

Breast: Pain, lump, nipple discharge, rash, history of breast disease, any surgery on the breasts.

Health Promotion: Performs breast self-examination, including its frequency and method used, last mammogram.

Axilla: Tenderness, lump or swelling, rash.

Urinary System: Frequency, urgency, nocturia (the number of times the person awakens at night to urinate, recent change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate), pain in flank, groin, suprapubic region, or low back.

Health Promotion: Measures to avoid or treat urinary tract infections, use of Kegel exercises after childbirth, Drinking fluids, Voiding with urge and not holding for extended periods of time, Female – proper wiping/hygiene.

Male Genital System: Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia.

Health Promotion: Performs testicular self-examination? How frequently?

Female Genital System: Menstrual history (age of menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding.

Health Promotion: Last gynecologic checkup and last Papanicolaou (Pap) test.

Sexual Health System: Begin with: “I usually ask all patients about their sexual health.” Then ask: Are you presently in a relationship involving intercourse? Are the aspects of sex satisfactory to the patient and partner? Routine use of condoms? Any dyspareunia (for female), any changes in erection or ejaculation (for male), and use of contraceptive? Is the contraceptive method satisfactory? Aware of contact with a partner who has any sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, or syphilis)?

Gastrointestinal System: Abdominal pain, nausea/vomiting, dysphagia, change in appetite. Change in bowel habits (constipation/diarrhea).

Health Promotion: Last colonoscopy

Neurologic System: Frequent headaches, history of seizures, weakness, numbness/tingling, Difficulty speaking, history of head injuries.

Peripheral Vascular System: Leg pain/cramps, lymph node enlargement, swelling in arms or legs.

FUNCTIONAL ASSESSMENT (5 points)

Intimate Partner Violence: Begin with open-ended questions “How are things at home?” and “Do you feel safe?” Follow-up with more close-ended questions: “Have you ever been emotionally or physically abused by a partner or someone important to you?” “Within the past year, have you been hit, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner?” “If yes, by whom?” “Number of times?” “Does your partner ever force you into having sex?” “Are you afraid of your partner or ex-partner?”

NEEDS ASSESSMENT/ANALYSIS OF DATA (20 points) – Please use the provided TSE/BSE pamphlets with the teaching portion of this assignment.

State purpose for instruction:

2 Teaching Learning SMART Goals related to the Male/Female System:

1.

2.

REFLECTION (20 points) – Separate Document (2-3 pages, APA format)

First, reflect on your interaction with the interviewee holistically. Consider the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process (if needed, refer to your text for a description of therapeutic communication and of the interview process). Finally, be sure your reflection addresses each of these questions:

· How did you prepare yourself and the patient for the interview

· Describe the environment in which the interview took place

· Describe the therapeutic communication techniques utilized during the interview

· Identify prior patient knowledge and practice of TSE/BSE

· Identify specifics of instructional content of TSE/BSE

· Identify teaching/learning strategies implemented/used.

· Describe how receptive the patient was to the instruction.

· Was there information that you wished you had obtained