Health

C

Health Assessment in Nursing Content of

Comprehensive Health History

I. Date: February 24,2011

II. Identifying Date:

A. Age: 30

B. Sex: Female

C. Race: African American

D. Place of Birth: Hattiesburg, Ms

E. Marital Status: Divorce

F. Occupation: Student

G. Religion: Baptist

III. Source of Referral:

IV. Source of history: Patient

V. Chief Complaint: none

VI. Present illness:

A. .Onset of Problem: none

B. Setting in which it developed: none

C. Manifestations and treatment: none

D. Location of symptoms: none

E. Quality of symptoms: none

F. Quantity or severity of symptoms: none

G. Timing (onset, duration and frequency) of symptoms

H. Setting symptoms occur: none

I. Factors that aggravate or relieve symptoms: none

J. Associated manifestations or related data from the patient’s chart: none

K. Absence of certain symptoms: none

L. Patient response to symptoms and incapacity: none

M. Underlying worries that led them to seek professional attention: none

N. Impact of illness or symptoms on the patient’s life: none

VII. Past History:

A. General state of health as patient perceives it: Moderately Healthy

B. Childhood illness: Chicken Pox, Measles, Mumps,

C. Adult illness: none

D. Psychiatric illness: none

E. Accidents and injuries: none

F. Operations: tubal ligation in 2003

G. Hospitalization: Delivery in 1996, 1998, 2000, 2003, and 2009

VIII. Current Health Status:

A. Allergeries: Penicillin

B. Immunizations: Hepatitis B, Tetanus, MMR

C. Screening tests: Pap smear

D. Environmental hazards: none

E. Exercise and leisure activities: Ride bikes 2 times per month, walk a mile every day

F. Sleep patterns: At least 6 hours of sleep most night

G. Diet: Fast food twice a day along with at 3(16oz.) caffeine...