7:53 1 A content.learntoday.info Comprehensive Health Assessment Form (50 points) Health History (5 pts total) Biographical data: (1 pts) No name or initial required Age: Marital status: M S Sep. Cohab. Birth date: Number of dependents: Educational level: Gender: F M Other Occupation (current or, if retired, past): Ethnicity/nationality: Source of history (who gave you the information and how reliable is that person): Present health history: (4 pts) Current medical conditions/chronic illnesses: Current medications: Medication/food/environmental allergies: Past health history: (10 pts total) Childhood illnesses: Ask about history of mumps, chickenpox, rubella, ear infections, throat infections, pertussis, and asthma. Hospitalizations/Surgeries: Include reason for hospitalization, year, and surgical procedures. Accidents/injuries: Include head injuries with loss of consciousness, fractures, motor vehicle accidents, burns, and severe lacerations. Major diseases or illnesses: Include heart problems, cancer, seizures, and any significant adult illnesses. Pertussis Immunizations (dates if known): Tetanus Diphtheria Mumps Rubella Polio Influenza Varicella Other Hepatitis B Recent travel/military services: Include travel within past year and recent and past military service. Date of last examinations: Physical examination Dental Vision Family History (Genogram) (10 points) Mother/Father/Siblings/Grandparents: include age (date of birth, if known 1, if indicated, 7:53 1 content.learntoday.info Family History (Genogram) (10 points) Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any major health issues, and, if indicated, cause and age at death Present as a genogram. Review of Systems (12 points total) Be sure to ask about symptoms specifically. General health status (1 pt): Ask about fatigue, pain, unexplained fever, night sweats, weakness, problems sleeping, and unexplained changes in weight. Integumentary (1 pt): Skin: Ask about change in skin color/texture, excessive bruising, itching, skin lesions, sores that do not heal, change in mole. Do you use sun screen? How much sun exposure do you experience? Hair: Ask about changes in hair texture and recent hair loss. Nails: Ask about changes in nail color and texture, splitting, and cracking. HEENT (2 pts): Head: Ask about headaches, recent head trauma, injury or surgery, history of concussion, dizziness, and loss of consciousness. Neck: Ask about neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the neck. Eyes: Ask about change in vision, eye injury, itching, excessive tearing, discharge, pain, floaters, halos around lights, flashing lights, light sensitivity, and difficulty reading. Do you use corrective lenses (glasses or contact lenses)? Ears: Ask about last hearing test, changes in hearing, ear pain, drainage, vertigo, recurrent ear infections, ringing in ears, excessive wax problems, use of hearing aids. Nose, Nasopharynx, Sinuses: Ask about nasal discharge, frequent nosebleeds, nasal obstruction, snoring, postnasal drip, sneezing, allergies, use of recreational drugs, change in smell, sinus pain, sinus infections. Mouth/Oropharynx: Ask about sore throats, mouth sores, bleeding gums, hoarseness, change voice quality, difficulty chewing or swallowing, change in taste, dentures and bridges. Respiratory (1 pt): Ask about frequent colds, pain with breathing, cough, coughing up blood, shortness of breath, wheezing, night sweats, last chest x-ray, PPD and results, and history of smoking Cardiovascular (1 pt.): Ask about chest pain, palpitations, shortness of breath, edema, coldness of extremities, color changes in hands and feet, hair loss on legs, leg pain with activity, paresthesia, sores that do not heal, and EKG and results. 7:54 1 A content.learntoday.info Breasts (1 pt.): (Remember men have breasts too) Ask about breast masses or lumps, pain, nipple discharge, swelling, changes in appearance, cystic breast disease, breast cancer, breast surgery, and reduction/enlargement. Do you perform BSE (when and how)? Date of last clinical breast examination, and mammograms and results. Gastrointestinal (1 pt.): Ask about changes in appetite, heartburn, gastroesophageal reflux disease, pain, nausea/vomiting, vomiting blood, jaundice, change in bowel habits, diarrhea, constipation, flatus, last fecal occult blood test and colonoscopy and results. Genitourinary (1 pt.): Ask about pain on urination, burning, frequency, urgency, incontinence, hesitancy, changes in urine stream, flank pain, excessive urinary volume, decreased urinary volume, nocturia, and blood in urine. Female/male reproductive (1 pt.): Both: Ask about lesions, discharge, pain or masses, change in sex drive, infertility problems, history of STDs, knowledge of STD prevention, safe sex practices, and painful intercourse. Are you current involved in a sexual relationship? If yes, heterosexual, homosexual,, bisexual? Number of sexual partners in the last 3 months. Do you use birth control? If yes, method(s) used. Female: Ask about menarche, description of cycle, LMP, painful menses, excessive bleeding, irregular menses, bleeding between periods, last Pap test and results, painful intercourse, pregnancies, live births, miscarriages, and abortions. Male: Ask about prostate or scrotal problems, impotence or sterility, satisfaction with sexual performance, frequency and technique for TSE, and last prostate examination and results. Musculoskeletal (1 pt.): Ask about fractures, muscle pain, weakness, joint swelling, joint pain, stiffness, limitations in mobility, back pain, loss of height, and bone density scan and results. Neurological (1 pt.): Ask about pain, fainting, seizures, changes in cognition, changes in memory, sensory deficits such as numbness, tingling and loss of sensation, problems with gait, balance, and coordination, tremor, and spasm. Psychosocial Profile (10 pts) Health practices and beliefs/self-care activities: Ask about type and frequency of exercise, type and frequency of self examination, oral hygiene practice (frequency of brushing/flossing), screening examinations (blood pressure, prostate, breast, glucose, etc.) Nutritional nattonna dolitolo 4 bu 7:54 1 Reader View Available Title of Assignment: Comprehensive Health History Purpose of Assignment: The first part of a health assessment is the history. It is contains critical information about the client. It is important for the nurse to feel comfortable asking all types of questions and to be able to identify the pertinent information for that client. This assignment is a comprehensive health history which would normally be done for a new client to a practice or admission. Course Competency(s): Identify the foundations of health assessment. Instructions: Using the provided form to guide the interview, collect as much information as the client is willing to divulge. In a combination of bulleted and narrative formatting, document the information gathered. Try not to be too wordy but, at the same time, be comprehensive in your documentation. Remember this is subjective information and should only be what the client tells you. Avoid making judgments until you determine what the strengths and weaknesses are. Submit this a word document Grading Rubric: See history form. 7:54 9 learning.rasmussen.edu = Rasmussen Home ย) Upload Assignment: Module 03 Written Assignment - Comprehensive Health History Module 03 Written Assignment - Comprehensive Health History Your comprehensive health history that was assigned in Module 01 is now due. Complete a comprehensive history, utilizing the form linked below, on either someone over the age of 65 or someone that you know has a lot of medical problems. Write the results in narrative format and include the family history as a genogram (see your text). Visit the following link for help with narrative format: http://rasmussen.libanswers.com/faq/32455 Comprehensive Health History Form Comprehensive Health History Assignment Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates. Save your assignment as a Microsoft Word document. (Mac users, please remember to append the ".docx" extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown below: Jstudent_exampleproblem_101504 Need Help? Click here for complete drop box When finished, make sure to click Submit. Optionally, click Save as Draft to save changes and continue working later, or click Cancel to quit without saving changes. Cancel Save Draft Submit
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