1 Mississippi College School of Nursing NUR 303- Health Assessment Student name:______________________________________________ Date:____________________________ Health History Patient Initials: ___________________Date: ________ Age: _____ Gender: _____ Biographical Data Town/City of Residence: Date of Birth: Marital Status: Primary Health Insurance: Supplemental Health Insurance: Advance Directive: Yes______ No_______ Source of Information: Reliability of Source: Present Health – Illness Status Describe your current health status: From whom do you seek health care? When was your last Complete physical examination: ____ Year – results if known ____No Dental Exam: ____ Year – results if known ____No Eye Exam: ____ Year – results if known ____No Which of the following have you had? Electrocardiogram (EKG): ____ Yes – results if known ____No Chest X-­­Ray: ____ Yes – results if known ____No Rectal Exam: ____ Yes – results if known ____No Mammogram:____ Yes – results if known ____No Pap Smear: ____ Yes – results if known ____No Prostatic Specific Antigen (PSA): ____ Yes – results if known ____No Blood Work: ____ Yes – Identify what and why; results if known ____No Current Medications—Name, Dose, Purpose, Frequency, Duration RX: __________________________________________________________ OTC: _________________________________________________________ Past History Medical History: Year, Diagnosis, Treatment: 2 Mississippi College School of Nursing NUR 303- Health Assessment Student name:______________________________________________ Date:____________________________ Surgical History: Year, Procedure - Name of Surgery: Hospitalization: Year, Reason - Health Problem, Treatment: Outpatient Care: Year, Reason - Health Problem, Treatment: Accidents and Injuries: Year, Type, Treatment: Mental Health: Year, Diagnosis, Treatment: Emotional Health: Year, History, Treatment: Allergies (Identify what and symptoms, treatment): Medication: ___________________________ Food: ________________________________ Environment: __________________________ Blood Type and Rh factor: _________________________ Transfusion History: ____Yes – tell when and what ____ None Substance Use: Tobacco: _________________ Drugs: __________________ Alcohol: _________________ Marijuana: ________________ Other: _________________ Childhood Illness: Have you ever had-----? Measles Yes (Year) No Mumps Yes (Year) No Chicken Pox Yes (Year) No Pertussis Yes (Year) No Strep throat Yes (Year) No Pneumonia Yes (Year) No Rheumatic fever Yes (Year) Immunizations: DPT Yes (Year) Hepatitis B Yes (Year) MMR Yes (Year) No No No Unknown Unknown Unknown Unknown Unknown Unknown No Unknown Unknown Unknown Unknown 3 Mississippi College School of Nursing NUR 303- Health Assessment Student name:______________________________________________ Date:____________________________ Polio Smallpox H1N1 Seasonal Flu Pneumonia Rotavirus Gardasil Yes (Year) Yes (Year) Yes (Year) Yes (Year) Yes (Year) Yes (Year) Yes (Year) No No No No No No No Family History Members: Initials and ages: Roles/responsibilities of each: Relationship: Nuclear family: Extended family: Home environment: Psychosocial History Education: Occupational History: Financial Background: Social Structure: Emotional Concerns: Unknown Unknown Unknown Unknown Unknown Unknown Unknown