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Date Submitted: 10/30/2011 05:22 PM
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...