Comprehensive Health Assessment Documentation Form submit for review 10. 8 (1).docx

Advanced Nursing Practice Field Experience
Comprehensive Health Assessment Documentation Form
Date:9/29/2019
Patient Information
Patient Initials A.H.
Age 37
Sex Female
Chief Complaint
No complaints of illness
History of Present Illness (HPI)
Uterine Fibroid Tumors since 2018
7 attributes of a symptom: location, quality, quantity/severity, timing, setting,
remitting/exacerbating factors, associated manifestations
Medications
Vitamin C- 500mg daily
Vitamin D- 1000 I U
DAILY
L-Lysine 1000mg
Allergies
Morphine
Benadryl
Medical HX (PMH)
Childhood No childhood disease
1

Adult Negative
Surgical Negative
Ob/Gyn Uterine Fibroid Tumors
Psychiatric Negative
Vaccinations
Flu Date:10/18 Pneumovax Date: refuse Tetanus Date: up-to -date
Family HX (specify family member affected/age at death)
Mother has hypertension
Father has Diabetes Type 2
Maternal Grandmother unknown
Paternal Grandfather unknown
Social/Environmental HX
 HTN- na
 DM-na
 Ca-na
 MI/CAD-na
 CVA- na
 TB- na
 Renal dz na
 Thyroid dz- na
 Suicide- na
 Alcoholism-na
 Substance abuse-
na
Born in: Detroit, Michigan
Education: High school Graduate/ 2
years of college
Occupation: Nurse
Family situation: Single/ no children
Transportation options: Reliable Car
Insurance:Blue Cross Blue Shield
Neighborhood: safe/ Suburban area
Language/Literacy: English
Access to emerging technologies:
Iphone, Macbook
Interests/Hobbies: painting, creating
jewelry, drawing, exercise, movie
2

goer
Review of Systems (ROS)
List findings, or check as negative. (If you have a positive finding, then describe its seven attributes in
the HPI or PMH)
Concerning Symptom Findings
General Wgt Δ; weakness; fatigue; fevers NEGATIVE
Skin Rash; lumps; sores; itching; dryness;
color change; Δ in hair/nails
NEGATIVE
Head Headache; head injury; dizziness
NEGATIVE
Eyes Vision Δ; corrective lenses; last eye
exam; pain; redness; excessive
tearing; double vision; blurred vision;
scotoma
Last eye exam 9/19
Wears corrective lenses
Ears Hearing Δ; tinnitus; earaches;
infections; discharge NEGATIVE
Nose/
Sinuses
Colds; congestion; discharge; itching;
hay fever; nosebleeds NEGATIVE
Throat Bleeding gums; dentures; last dental
exam; sore tongue; dry mouth; sore
throats; hoarse
LAST DENTAL
APPOINTMENT 6/2019
Neck Lumps; swollen glands; goiter; pain;
neck stiffness
NEGATIVE
Breasts Lumps; pain; discomfort; nipple
discharge NEGATIVE
Pulmonar
y
Cough—productive/non-productive;
hemoptysis; dyspnea; wheezing;
pleuritic pains
NEGATIVE
Cardiac Chest pain or discomfort; palpitations;
dyspnea; orthopnea; PND; edema NEGATIVE
3

G/I Appetite Δ; jaundice; nausea/emesis;
dysphagia; heartburn; pain;
belching/flatulence; Δ in bowel habits;
hematochezia; melena; hemorrhoids;
constipation; diarrhea; food
intolerance
NEGATIVE
Urinary Frequency; nocturia; urgency; dysuria;
hematuria; incontinence
MALES : caliber of urinary stream;
hesitancy; dribbling
NEGATIVE
G/U
(General)
Sexual habits; interest; function;
satisfaction; use of birth control
methods; HIV exposure
NEGATIVE
Male G/U Discharge from or sores on penis;
testicular pain/masses NA
Female
G/U