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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate:_October 10, 2018_________Patient InformationPatient InitialsSFAge48SexMChief ComplaintPatient denies any acute complaint. Pt is requesting a comprehensive health assessment as part of his annual physical examination.History of Present Illness (HPI)HPI: no specific complaintsLocation: noneQuality: noneSeverity: noneTiming: noneSetting: noneRemitting / exacerbating factors: noneAssociated manifestations: none7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsPatient reports no current medicationsAllergiesNo known drug allergies1
Medical HX (PMH)ChildhoodChicken pox (unknown age). Denies any other illnesses.AdultDenies any acute or chronic medical conditionsSurgicalJaw surgery age 19 (atraumatic)Gallbladder removed mid-30s (no complications)Ob/GynN/APsychiatricPatient denies any psychiatric illness; denies depression; denies loss of interest in normal activitiesVaccinationsFluDate: 08/2018PneumovaxDate: has not receivedTetanusDate: 06/2014Family HX (specify family member affected/age at death)Mother and father both still living, both in good health.Maternal grandmother died from a stroke in her 60s.Denies any history of cardiac disease, HTN or diabetes in family.2
Social/Environmental HXHTNDMCaMI/CADCVATBRenal dzThyroid dzSuicideAlcoholismSubstance abuseBorn in: Honolulu, HawaiiEducation: Associates DegreeOccupation: Retail ManagementFamily situation: Married, 3 childrenTransportation options: Own vehicleInsurance: yesNeighborhood: Rural; owns homeLanguage/Literacy: English; able to read and writeAccess to emerging technologies: yesInterests/Hobbies: Gaming; family activities; outdoor recreation equipment3
Review of Symptoms (ROS)List findings, or check as negative.(If you have a positive finding, then describe its seven attributes inthe HPI or PMH)Concerning SymptomFindingsGeneralWgt Δ; weakness; fatigue; feversNegativeSkinRash; lumps; sores; itching; dryness; color change; Δ in hair/nailsNegativeHeadHeadache; head injury; dizzinessNegativeEyesVision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotomaNegativeLast eye exam 1 month ago (employment)EarsHearing Δ; tinnitus; earaches; infections; dischargeNegativeNose/SinusesColds; congestion; discharge; itching; hay fever; nosebleedsNegativeThroatBleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarseNegativeLast dental exam 3 months agoNeckLumps; swollen glands; goiter; pain; neck stiffnessNegativeBreastsLumps; pain; discomfort; nipple dischargeNegativePulmonaryCough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic painsNegativeCardiacChest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edemaNegativeG/IAppetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain;