NUR2092 WRITE-UP\u2014HEALTH HISTORY Classroom Assignment Week Two
\nDate __________________________ Examiner ______________________
\n1. Biographic Data Name _______________________________________________ Phone________________________ Address____________________________________________________________________________ Birthdate ________________________________ Birthplace _________________________________ Age __________ Gender __________ Marital Status ______________ Occupation _______________ Race\/ethnic origin __________________________________ Employer ________________________
\n2. Source and Reliability<\/p>\n
3. Reason for Seeking Care<\/p>\n
4. Present Health or History of Present Illness<\/p>\n
Past Health
\nDescribe general health ______________________________________________________________ Childhood illnesses __________________________________________________________________ Accidents or injuries (include age) ______________________________________________________ Serious or chronic illnesses (include age) ________________________________________________ Hospitalizations (what for? location?) ____________________________________________________ Operations (name procedure, age) ______________________________________________________ Obstetric history: Gravida ____________ Term ____________ Preterm ____________ (# Pregnancies) (# Term pregnancies) (# Preterm pregnancies) Ab\/incomplete _____________________ Children living _____________________ (# Abortions or miscarriages) _____
\nCourse of pregnancy__________________________________________________________________ (Date delivery, length of pregnancy, length of labor, baby\u2019s weight and sex, vaginal delivery or cesarean section, complications, baby\u2019s condition) Immunizations_____________________________________________________________________
\nLast examination date: Physical ________________
\nDental ________________ Vision ________________ Allergies _________________________________ Reaction __________________________________<\/p>\n
Current medications _________________________________________________________________ _
\n6. Family History\u2014Specify Which Relative(s)
\nHeart disease___________________________ High blood pressure______________________ Stroke_________________________________ Diabetes_______________________________
\nBlood disorders_________________________ Breast or ovarian cancer___________________
\nCancer (other)__________________________ Sickle cell______________________________ Arthritis_______________________________ Allergies_______________________________ Asthma _______________________________ Obesity________________________________ Alcoholism or drug addiction ______________
\nMental illness ___________________________ Suicide ________________________________
\nSeizure disorder ________________________ Kidney disease __________________________ Tuberculosis _____
\nReview of Systems (Circle\/highlight both past health problems that have been resolved and current problems, including date of onset.)
\nGeneral Overall Health State: Present weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats or night sweats
\nSkin: History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion
\nHair: Recent loss, change in texture
\nNails: Change in shape, color, or brittleness
\nHealth Promotion: Amount of sun exposure, method of self-care for skin and hair
\nHead: Any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigo
\nEyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts
\nHealth Promotion Eyes: Wears glasses or contacts, last vision check or glaucoma test, how coping with loss of vision, if any
\nEars: Earaches, infections, discharge and its characteristics, tinnitus, or vertigo
\nHealth Promotion Ears: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning ears<\/p>\n
Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell
\nMouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste
\nHealth Promotion\/Mouth & Throat: Pattern of daily dental care, use of prostheses (dentures, bridge), and last dental checkup
\nNeck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter
\nBreast: Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts Axilla: Tenderness, lump or swelling, rash
\nHealth Promotion Breast: Performs breast self-examination, including frequency and method used, last mammogram and results
\nRespiratory System: History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure Health Promotion Respiratory: Last chest x-ray examination
\nCardiovascular System: Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion it takes to produce dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia
\nHealth Promotion Cardiovascular: Date of last ECG or other heart tests and results
\nPeripheral Vascular System: Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers Health Promotion Peripheral Vascular: If work involves long-term sitting or standing, avoid crossing legs at the knees; wear support hose.
\nGastrointestinal System: Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula)
\nHealth Promotion Gastrointestinal: Use of antacids or laxatives
\nUrinary System: Frequency, urgency, nocturia (the number of times awakens at night to urinate, recent change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or low back
\nHealth Promotion Urinary: Measures to avoid or treat urinary tract infections, use of Kegel exercises
\nMale Genital System: Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia
\nHealth Promotion Male Genital: Perform testicular self-examination? How frequently?
\nFemale Genital System: Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding.
\nHealth Promotion Female Genital: Last gynecologic checkup, last Pap test and results
\nSexual Health: Presently in a relationship involving intercourse? Are aspects of sex satisfactory to you and partner, any dyspareunia (for female), any changes in erection or ejaculation (for male), use of contraceptive, is contraceptive method satisfactory? Use of condoms, how frequently? Aware of any contact with partner who has sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV\/AIDS, syphilis)?
\nMusculoskeletal System: History of arthritis or gout. In the joints: pain, stiff-ness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gait prob-lems or problems with coordinated activities. In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease.
\nHealth Promotion Musculoskeletal: How much walking per day? What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? Any mobility aids used?
\nNeurologic System: History of seizure disorder, stroke, fainting, blackouts. In motor function: weakness, tic or tremor, paralysis, coordination problems. In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent or distant, disorientation). In mental status: any nervousness, mood change, depression, or any history of mental health dysfunction or hallucinations.
\nHematologic System: Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions. Endocrine System: History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat or cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy.
\nFunctional Assessment (Including Activities of Daily Living)
\nSelf-Esteem, Self-Concept: Education (last grade completed, other significant training) ______________
\nFinancial status (income adequate for lifestyle and\/or health concerns) __________
\nValue-belief system (religious practices and perception of personal strengths) ___________
\nSelf-care behaviors ______________________
\nActivity and Exercise: Daily profile, usual pattern of a typical day ________________________________
\nIndependent or needs Helpance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, climbing stairs _________________________________
\nLeisure activities ________________________________________
\nExercise pattern (type, amount per day or week, method of warm-up session, method of monitoring
\nSleep and Rest: Sleep patterns, daytime naps, any sleep aids used ___________________
\nNutrition and Elimination: Record 24-hour diet recall. _______________________________________ _____________________________________________________________________________________
\nIs this menu pattern typical of most days? ___________________________________________________
\nWho buys food? ____________________________
\nWho prepares food? __________________________
\nFinances adequate for food? __________________________________
\nWho is present at mealtimes? __________________________________
\nInterpersonal Relationships and Resources: Describe own role in family _________________________
\nHow getting along with family, friends, co-workers, classmates ______________________
\nGet support with a problem from? ______________________________________________
\nHow much daily time spent alone? _______________________________________________________ Is this pleasurable or isolating? ___________________________________________________________
\nCoping and Stress Management: Describe stresses in life now __________________________________ _____________________________________________________________________________________ Change(s) in past year ______________________________________________
\nMethods used to relieve stress _______________________
\nAre these methods helpful? ___________________________
\nPersonal Habits:
\nDaily intake caffeine (coffee, tea, colas) ______________________________________
\nSmoke cigarettes? ____________________________ Number packs per day ______________
\nDaily use for how many years __________________ Age started ___________
\nEver tried to quit? ____________________________ How did it go? _____________________________
\nDrink alcohol? ____________________ Date of last alcohol use _______
\nAmount of alcohol that episode __________________________________________________________
\nOut of last 30 days, on how many days had alcohol? ____________________________________
\nEver told had a drinking problem? ________________________________________________________ Any use of street drugs? ___________Marijuana? _________________________________
\nCocaine? __________________________________ Crack cocaine? ______________________________ Amphetamines? _____________________________ Heroin? __________________
\nPrescription painkillers? _____________________ Barbiturates? _______________________________ LSD? _____________________________________
\nEver been in treatment for drugs or alcohol? ________________________________________________
\nEnvironment and Hazards: Housing and neighborhood (type of structure, live alone, know neighbors) _____________________________________________________________________________________
\nSafety of area _________________________________________________________________________ Adequate heat and utilities ____________________________________________________________
\nAccess to transportation ____________________________________________________________
\nInvolvement in community services _______________________________________________________ Hazards at workplace or home ___________________________________________________________ Use of seatbelts ____________________________________________________________________
\nTravel to or residence in other countries ___________________________________________________ Military service in other countries ________________________________________________________ Self-care behaviors _____________________________________________________________________ Intimate Partner Violence: How are things at home? Do you feel safe? __________________
\nEver been emotionally or physically abused by your partner or someone important to you___-
\nEver been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner? _____________________________________________________________________________________ Partner ever force you into having sex? ____________________________________________________ Are you afraid of your partner or ex-partner? ________________________________
\nOccupational Health:
\nPlease describe your job. ______________________________________________
\nWork with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)? ___________________________________________________________________________________
\nAny equipment at work designed to reduce your exposure?
\nAny work programs designed to monitor your exposure? _________________________________
\nAny health problems that you think are related to your job? _____________________________
\nWhat do you like or dislike about your job? _________________________________________________
\nPerception of Own Health:
\nHow do you define health? ________________________________________
\nView of own health now ________________________________________________________________
\nWhat are your concerns? ________________________________________________________________
\nWhat do you expect will happen to your health in future? _<\/p>\n
———-<\/p>\n
NUR2092 WRITE-UP\u2014HISTORY OF HEALTH Week Two of the Classroom Assignment<\/p>\n
1. Name of the biographical data Address Gender Marital Status ______________ Occupation _______________ Race\/ethnic origin __________________________________ Employer ________________________<\/p>\n
2. Source and Reliability<\/p>\n
3. Reason for Seeking Care<\/p>\n
4. Present Health or History of Present Illness<\/p>\n
Past Health<\/p>\n
Describe general health ______________________________________________________________ Childhood illnesses __________________________________________________________________ Accidents or injuries (include age) ______________________________________________________ Serious or chronic illnesses (include age) ________________________________________________ Hospitalizations (what for? location?) ____________________________________________________ Operations (name procedure, age) ______________________________________________________ Obstetric history: Gravida ____________ Term ____________ Preterm ____________ (# Pregnancies) (# Term pregnancies) (# Preterm pregnancies) Ab\/incomplete _____________________ Children living _____________________ (# Abortions or miscarriages) _____<\/p>\n
Course of pregnancy<\/p>\n
__________________________________________________________________ (Date delivery, length of pregnancy, length of labor, baby\u2019s weight and sex, vaginal delivery or<\/p>\n
_____________________
\nYour health goals ______________________________________________________________________
\nYour expectations of nurses, physicians ___________________________________________________<\/p>\n
——–<\/p>\n","protected":false},"excerpt":{"rendered":"
NUR2092 WRITE-UP\u2014HEALTH HISTORY Classroom Assignment Week Two Date __________________________ Examiner ______________________ 1. Biographic Data Name _______________________________________________ Phone________________________ Address____________________________________________________________________________ Birthdate ________________________________ Birthplace _________________________________ Age __________ Gender\u2026<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[9033,7586,1386,7589,9034,9031,7587,7588,7584,7585,9032],"tags":[8809,7838,8811,8808,8813,8807,8806,8814,8810,8812],"class_list":["post-106545","post","type-post","status-publish","format-standard","hentry","category-assignment-help-uae","category-best-dissertation-writing-service-in-australia","category-best-research-paper-writing-services-in-usa","category-capstone-project-writing-service","category-cheap-essay-writing-services-china","category-essay-writing-service-usa","category-legitimate-phd-dissertation-writing-services-usa","category-term-paper-writing-service","category-thesis-writing-service-in-canada","category-uae-best-dissertation-writing-help-service","category-write-my-essay-australia","tag-best-master-thesis-writing-service","tag-best-thesis-writing-services","tag-cheap-thesis-writing-services","tag-master-thesis-help","tag-master-thesis-writing-service","tag-thesis-help-online-free","tag-thesis-writing-help-online","tag-thesis-writing-services-cost","tag-thesis-writing-services-near-me","tag-thesis-writing-services-reviews"],"_links":{"self":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts\/106545","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/comments?post=106545"}],"version-history":[{"count":0,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts\/106545\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/media?parent=106545"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/categories?post=106545"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/tags?post=106545"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}