Health Assessment TAKE HOME ASSIGNMENT CH 4 The Complete Health History Name - Section - Date

Health Assessment TAKE HOME ASSIGNMENT
CH 4 The Complete Health History
Name _______________________________________________ Section_____ Date_____________

DIRECTIONS: You will perform a complete health history on a non- classmate and your professor will assign you to
interview either a young adult (age 20-39), a middle aged adult (age 40-59), or an aged adult (age 60-80+)
(Reason for seeking care may be something from the person’s past). Collect all 8 areas of data on that person
(Use Jarvis pp 50-59 as guide for what info to collect)
Use other side of paper as needed to document data that won’t fit on front of page
1. Biographical Initials DOB Gender Marital Status

data MV 08/07/1996 Female Single
Race/Ethnicity/Birthplace Occupation
Caucasian, Bosnian, Bosnia LPN
How you know this person
Classmate
2. Reason for
seeking care in Left knee pain
person’s own
words
3. Present health Symptom:
or history of
present . Explore P Provocative or Palliative (what brings it on? what were you doing? What made it better? worse?)
the symptom using Excessive movement @ work/ daily life brings on pain, stretching makes it better, excessive
PQRSTU (see p77) movement makes it worse
Q Quality or Quantity (How does it look, feel, sound? How intense/severe is it?)
Looks normal, makes a popping sound
R Region or Radiation (where is it? Does it spread anywhere?)

Stays in L knee
S Severity Scale (How bad is it- on a scale 1-10? Is it getting better, worse or staying same?)
4 (achy pain), isn’t getting better
T Timing (Onset: When did it first occur?: Duration: How long did it last?; Frequency: How often
does it occur?)
4 months ago, about 3 times a week
U Understand Patient’s Perception of the problem (what does he/she think it means?)
Needs to exercise more  needs more flexibility
5 Past history Accidents /Injuries in past 10 years

Patient denies accidents/injuries in the past 10 years
Serious /Chronic Illnesses: now/past

Patient denies serious chronic illnesses
Hospitalizations/Operations in past 10 years

Patient denies hospitalizations
Allergies
NKA/NKDA
Current Medications (list name, dose ,frequency, reason taken of each):
Name Dose/Frequency Reason Taken
Tylenol 650mg Pain
6. Family history: Grandfather

Age and Health –o- On mother: died of lung cancer (40s)
r Cause of Death On father: natural death (80s)
and at what age :
Grandmother
On mother: died of diabetes (80s)
On father: died of diabetes (80s)
Father
No known illnesses
Mother
Pre-diabetic
Sibling
No siblings
7 Review of ASK: “How would you describe your general health state?”
systems Reports usual health “OK.” No recent weight change, slight fatigue from work, no weakness, fever,
or sweats
Use TEXT (pp 54- (“Has anyone told you about a problem with your…..?) [Then describe problem]
57) for what to Skin
ask & state what No change in skin color, pigmentation, or nevi. No pruritus, rash, lesions. No history of skin disease.
you found when
you asked Hair
No loss or change in texture
Eyes
No difficulty of vision or diplopia. No eye pain, inflammation, discharge, lesions. No history of
glaucoma or cataracts.
Ears
Hearing issues/ loss in right ear. No earaches, no infections now, no discharge, tinnitus, or vertigo
Nose/ Sinuses
No discharge, no sinus pain, nasal obstruction, epistaxis, or allergy
Mouth/ Throat
No mouth pain, bleeding gums, toothache, sores or lesions in mouth, dysphagia, hoarseness, or sore
throat. Self care: brushes teeth twice a day
Neck
No pain, limitation of motion, lumps, or swollen glands
Breast
No pain, lumps, nipple discharge, rash, swelling, or trauma. No history of breast disease in self or
mother. No surgery
Axilla & Lungs/Breathing (Respiratory)

History of lung disease in grandfather on mother’s side. No chest pain with breathing; no wheezing
or SOB. No smoking
Heart, Arteries, Veins (Cardiovascular)

No chest pain, palpitation, cyanosis, fatigue, dyspnea with exertion, orthopnea, paroxysmal
nocturnal dyspnea, nocturia, edema. No history of heart murmur, hypertension, coronary artery
disease, or anemia.
Stomach/Intestines (Gastrointestinal)
Appetite good with no recent change. No food intolerance, heartburn, indigestion, pain in abdomen,
nausea, or vomiting. No history of ulcers, liver or gallbladder disease, jaundice, appendicitis, or
colitis.
Bladder/Urethra (Urinary)
No dysuria, frequency, urgency, nocturia, hesitancy, or straining. No pain in flank, groin, suprapubic
region. Urine color yellow; no history of kidney disease
Genitals
No vaginal itching, discharge, sores, or lesions
Muscles/Bones/Joints (Musculoskeletal)
No history of arthritis, gout. Some joint pain, stiffness, swelling, no deformity, slight limitation of
motion. Some muscle pain, no weakness. Self care: exercises 3 times a week
Nerves/Balance/Sensations (Neurologic)
No history of seizure disorder, stroke, fainting. No blackouts. No weakness, tremor, paralysis,
problems with coordination, difficulty speaking or swallowing. No numbness or tingling. Not aware
of memory problem, nervousness or mood change. Denies any suicidal ideation or intent during
adolescent years or now.
8.Functional Self-Esteem/ Self Concept

assessment/ADL Graduated high school and went to LPN school. Works at Brook’s Rehab. Believes to be honest, kind
Use the TEXT (pp and sociable. Believes nursing to be very rewarding and helpful to self fulfilment.
57-59)) to ask
these questions. Activity/Exercise
Works out 3-4 days a week for an hour
NOTE that for
some topics you Sleep/Rest
may not want to Wakes up at 8am and goes to bed at 1 am on a typical day. Some complaint of fatigue
ask direct
questions but
rather conclude Interpersonal relationships/Resources
findings based on Describes family life growing up normal. Only family is her mother and father. All other family back
your observations in Bosnia where she is from. Frequently socializes with close friends
Spiritual Resources
Believes in God, prays daily
Coping and Stress Management

Goes out with friends 1-2 times a week for stress relief or goes to the beach
Personal Habits
Patient denies any personal habits
Alcohol
Drinks socially when out with friends 1-2 times a week
Street Drugs
Patient denies use of any illicit street drugs
Environment/Hazards
Patient believes to have adequate housing, safe neighborhood. Uses seatbelt, forgets sunscreen
Intimate Partner Violence

Patients denies any intimate partner violence
Occupational Health
Practices standard health precautions when at work with sick patients. Up to date with all vaccines
and gets annual flu shot and PPD test at work.
THIS PAGE is for YOU to do YOUR OWN FAMILY TREE or GENOGRAM
(See sample on page 53 in TEXT)
Please include first names, ages, & medical conditions on all people in your tree. How to find out about medical conditions: Ask each
person what medications they take; the “indication” for the medication is their medical condition. Include cause of death in the
deceased – and at what age deceased.. Must include 3 generations; (1) grandparents, (2) parents and their siblings, (3) you and
your siblings and cousins. (add squares & circles as needed)
_________________________________________________________FAMIILY TREE
Student’s name

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Health Assessment TAKE HOME ASSIGNMENT

CH 4 The Complete Health History

Name _____________________________________________ Section_ Date___________

1. Biographical Initials DOB Gender Marital Status

R Region or Radiation (where is it? Does it spread anywhere?)

5 Past history Accidents /Injuries in past 10 years

Serious /Chronic Illnesses: now/past

Hospitalizations/Operations in past 10 years

6. Family history: Grandfather

Axilla & Lungs/Breathing (Respiratory)

Heart, Arteries, Veins (Cardiovascular)

8.Functional Self-Esteem/ Self Concept

Coping and Stress Management

Intimate Partner Violence

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