NUR2092 WRITE-UP\u2014HEALTH HISTORY Classroom Assignment Week Two
\nDate ___4\/16\/22____________ Examiner _ __________
\n1. Biographic Data Name: ___ _____________________________________ Phone_________________ Address__ Il_________________ Birthdate ________________________________ Birthplace ______ ________ Age __37________ Gender _____Male_____ Marital Status _Married _____________ Occupation __Independent Contractor________ Race\/ethnic origin __ _____________________ Employer __ __________________
\n2. Source and Reliability: From Patient<\/p>\n
3. Reason for Seeking Care: Annual medical check-up<\/p>\n
4. Present Health or History of Present Illness: None<\/p>\n
Past Health
\nDescribe general health __Good____________________________________________________ Childhood illnesses ____None____________________________________________________________ Accidents or injuries (include age) ___None________________________________________________ Serious or chronic illnesses (include age) _None______________________________________________ Hospitalizations (what for? location?) ___None_______________________________________________ Operations (name procedure, age) _____None_______________________________________________ Obstetric history: Gravida __N\/A__________ Term ___N\/A_________ Preterm ___N\/A_________ (# Pregnancies) (# Term pregnancies) (# Preterm pregnancies) Ab\/incomplete _N\/A____________________ Children living _____N\/A________________ (# Abortions or miscarriages) _N\/A____
\nCourse of pregnancy____N\/A____________________________________________________________ (Date delivery, length of pregnancy, length of labor, baby\u2019s weight and sex, vaginal delivery or cesarean section, complications, baby\u2019s condition) Immunizations: _Up to date immunization____________________________________________
\nLast examination date: Physical ________________
\nDental ____9\/_14\/2021___________ Vision __11\/17\/2021________ Allergies __None____________ Reaction ___None_________________________<\/p>\n
Current medications ___None___________________________________________ _
\n6. Family History\u2014Specify Which Relative(s)
\nHeart disease: _None_______________________ High blood pressure: _Father_____________
\nStroke: _Father______________________ Diabetes: ___None ____________________________
\nBlood disorders: _______None _______________ Breast or ovarian cancer: ____None________
\nCancer (other): ____None______________________ Sickle cell: __None __________________
\nArthritis: ____None_____________________ Allergies: ____None___________________________ Asthma: None __________________
\n____ Obesity: ___None____________________________ Alcoholism or drug addiction _None _____________
\nMental illness _None____________________ Suicide ___None____________________________
\nSeizure disorder __N\/A______________________ Kidney disease __N\/A________________________ Tuberculosis _N\/A____
\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. None
\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: None
\nHair: Recent loss, change in texture: None
\nNails: Change in shape, color, or brittleness: None
\nHealth Promotion: Amount of sun exposure, method of self-care for skin and hair: N\/A
\nHead: Any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigo: None
\nEyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts: None
\nHealth Promotion Eyes: Wears glasses or contacts, last vision check or glaucoma test, how coping with loss of vision, if any: None
\nEars: Earaches, infections, discharge and its characteristics, tinnitus, or vertigo: None
\nHealth Promotion Ears: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning ears: None<\/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: None
\nMouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste: None
\nHealth Promotion\/Mouth & Throat: Pattern of daily dental care, use of prostheses (dentures, bridge), and last dental checkup: None
\nNeck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter: None
\nBreast: Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts Axilla: Tenderness, lump or swelling, rash: N\/A
\nHealth Promotion Breast: Performs breast self-examination, including frequency and method used, last mammogram and results: N\/A
\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: None
\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: None
\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. None
\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: None
\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: None
\nHealth Promotion Urinary: Measures to avoid or treat urinary tract infections, use of Kegel exercises: None
\nMale Genital System: Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia: None
\nHealth Promotion Male Genital: Perform testicular self-examination? How frequently? None
\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. N\/A
\nHealth Promotion Female Genital: Last gynecologic checkup, last Pap test and results; N\/A
\nSexual Health: Presently in a relationship involving intercourse? Yes. Are aspects of sex satisfactory to you and partner? Yes. any dyspareunia (for female), any changes in erection or ejaculation (for male) None. use of contraceptive, is contraceptive method satisfactory? N\/A. Use of condoms, how frequently? None. Aware of any contact with partner who has sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV\/AIDS, syphilis)? None
\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 problems 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. None
\nHealth Promotion Musculoskeletal: How much walking per day? 2 miles What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? None. Any mobility aids used? None
\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. None
\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. None
\nFunctional Assessment (Including Activities of Daily Living)
\nSelf-Esteem, Self-Concept: Education (last grade completed, other significant training) __University____________
\nFinancial status (income adequate for lifestyle and\/or health concerns) __________
\nValue-belief system (religious practices and perception of personal strengths) ___________
\nSelf-care behaviors _Eating a good balance diet and very active_____________________
\nActivity and Exercise: Daily profile, usual pattern of a typical day __Exercise once in a week by walking 2 miles ______________________
\nIndependent or needs Helpance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, climbing stairs ___None______________________________
\nLeisure activities ____Spend time with family____________________________________
\nExercise pattern (type, amount per day or week, method of warm-up session, method of monitoring: Walking
\nSleep and Rest: Sleep patterns, daytime naps, any sleep aids used __None_________________
\nNutrition and Elimination: Record 24-hour diet recall. __No diet restriction _____________________________________ _____________________________________________________________________________________
\nIs this menu pattern typical of most days? ___________________________________________________
\nWho buys food? __The Patient buy his food__________________________
\nWho prepares food? ___The patient\u2019s wife prepares the food and the patient Help in the kitchen______________________
\nFinances adequate for food? ___Yes_______________________________
\nWho is present at mealtimes? __The patient ________________________________
\nInterpersonal Relationships and Resources: Describe own role in family __Father_______________________
\nHow getting along with family, friends, co-workers, classmates _Patient get along very well with friends and family_____________________
\nGet support with a problem from? ____wife __________________________________________
\nHow much daily time spent alone? ____None spent most time with family_______________________ Is this pleasurable or isolating? Pleasurable____________________________________________
\nCoping and Stress Management: Describe stresses in life now __Combining work and family together ________________________________ _____________________________________________________________________________________ Change(s) in past year ______None________________________________________
\nMethods used to relieve stress __relaxing and movie_____________________
\nAre these methods helpful? _Yes__________________________
\nPersonal Habits:
\nDaily intake caffeine (coffee, tea, colas) __None____________________________________
\nSmoke cigarettes? ___None________________ Number packs per day ___None___________
\nDaily use for how many years ___N\/A___________ Age started __N\/A_________
\nEver tried to quit? __N\/A__________________ How did it go? ___N\/A___________________
\nDrink alcohol? _No__________________ Date of last alcohol use __N\/A_____
\nAmount of alcohol that episode ______N\/A____________________________________________________
\nOut of last 30 days, on how many days had alcohol? ____________________________________
\nEver told had a drinking problem? __No__________________________________________________ Any use of street drugs? __None______Marijuana? _None________________________________
\nCocaine? ____None______________________________ Crack cocaine? __N\/A__________________ Amphetamines? __N\/A______________ Heroin? ____N\/A______________
\nPrescription painkillers? ___N\/A____________ Barbiturates? ___N\/A____________________________ LSD? ____N\/A_________________________________
\nEver been in treatment for drugs or alcohol? __N\/A______________________________________________
\nEnvironment and Hazards: Housing and neighborhood (type of structure, live alone, know neighbors) _City, Live with family ____________________________________________________________________________________
\nSafety of area ___Good________________________________________________________________ Adequate heat and utilities _____Good___________________________________________________
\nAccess to transportation ____Yes________________________________________________________
\nInvolvement in community services ___No_________________________________________________ Hazards at workplace or home ___None___________________________________________________ Use of seatbelts _______Yes_____________________________________________________________
\nTravel to or residence in other countries ___No_____________________________________________ Military service in other countries ___No_______________ Self-care behaviors _______________ Intimate Partner Violence: None How are things at home? Good Do you feel safe?___Yes____________
\nEver been emotionally or physically abused by your partner or someone important to you: __No_-
\nEver been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner? No______________________________________________________________________________ Partner ever force you into having sex? _No__________________________________________ Are you afraid of your partner or ex-partner? ____No____________________________
\nOccupational Health:
\nPlease describe your job. ___Independent Contractor___________________________
\nWork with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)? _________________No__________________________________________________________________
\nAny equipment at work designed to reduce your exposure? No
\nAny work programs designed to monitor your exposure? ____No_____________________________
\nAny health problems that you think are related to your job? __No___________________________
\nWhat do you like or dislike about your job? ___I like the fact that is flexible for me _________________
\nPerception of Own Health:
\nHow do you define health? _My health has been good so far_________________________
\nView of own health now __No major illness which I\u2019m happy about. Everything looks perfect______________________________________________________________
\nWhat are your concerns? __None ______________________________________________________________
\nWhat do you expect will happen to your health in future? ___considering the fact that I don\u2019t have any underlying illness, I expect to be healthy in future like I am right now. ____________________
\nYour health goals __continue to maintain my weight, eat more of healthy food to keep healthier____________________________________________________________________
\nYour expectations of nurses, physicians _I expect the nurse and physicians to responds to my concerns\/ needs when needed and also continue to treat all the patient with respect and love like they have been doing __________________________________________________<\/p>\n
====<\/p>\n
NUR2092 WRITE-UP\u2014HISTORY OF HEALTH Classroom Assignment Week Two Date ___4\/16\/22____________ Examiner _ __________
\n1. Biographic Data Name: ___ _____________________________________ Phone _________________ Address__ Il_________________ Birthdate ________________________________ Birthplace ______ ________ Age __37________ Gender _____Male_____ Marital Status _ Married _____________ Occupation __Independent Contractor________ Race\/ethnic origin __ _____________________ Employer __ __________________
\n2. Source and Reliability: From Patient<\/p>\n
3. Reason for Seeking Care: Annual medical check-up<\/p>\n
4. Present Health or History of Present Illness: None<\/p>\n
Past Health
\nDescribe general health __Good____________________________________________________ Childhood illnesses ____None____________________________________________________________ Accidents or injuries (include age) ___None________________________________________________ Serious or chronic illnesses (include age) _ None______________________________________________ Hospitalizations (what for? location?) ___None_______________________________________________ Operations (name procedure, age) _____None_______________________________________________ Obstetric history: Gravida __N\/A__________ Term ___N\/A_________ Preterm ___N\/A_________ (# Pregnancies) (# Term pregnancies) (# Preterm pregnancies) Ab\/incomplete _N\/A____________________ Children living _____N\/A________________ (# Abortions or miscarriages) _N\/A____
\nCourse of pregnancy
\n____N\/A____________________________________________________________ ( Date delivery, length of pregnancy, length of labor, baby\u2019s weight and sex, vaginal<\/p>\n","protected":false},"excerpt":{"rendered":"
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