Nursing

Thank you for getting my order, I want to inform you that The Comprehensive Health History is an interview that is usually done for a new client/patient, the Family Genogram needs to be filled up with the same information (is about the same patient and family). I hope this helps Thank you again

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Comprehensive Health Assessment Form

(50 points)

Health History  (5 pts total)

Biographical data: (1 pts)

No name or initial required

Age:  25      Marital status: Single

Birth date: 17/6/1998   Number of dependents: 0

Educational level: College

Gender: Male

Occupation (current or, if retired, past): Accountant

Ethnicity/nationality: Caucasian

Source of History: The patient was the source of information. The information is very reliable since it comes first hand from the patient.

Present health history: (4 pts)

Current medical conditions/chronic illnesses: The patient has indigestion issues and heart problems.

Current medications: No current medications

 

Medication/food/environmental allergies: Food allergies (Gluten)

 

Past health history: (10 pts total)

Childhood illnesses: Patient has no history of mumps, chickenpox, rubella, ear infections, pertussis, and asthma. Patient has had throat infections throughout his life.

 

Hospitalizations/Surgeries: Patient was hospitalized 2 years ago for rotator cuff and implantation of a pace maker.

 

Accidents/injuries: Patient has not had any head injuries with loss of consciousness, fractures, motor vehicle accidents, burns, and severe lacerations.

Major diseases or illnesses: The patient has had heart problems which led to implantation of a pace maker since 2018.

 

Immunizations (dates if known): The immunization dates are not known but the patient has all immunizations up to date

Tetanus YES Diphtheria YES   Pertussis YES Mumps YES

Rubella YES Polio YES   Hepatitis B YES   Influenza YES

Varicella YES Other

Recent travel/military services: Patient has not travelled lately due to the COVID-19 restrictions.

 

Date of last examinations:

Physical examination 09/12/2021 Vision 10/2/2020 Dental 7/9/2021

 

 

Family History (Genogram) (10 points)

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