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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate:9/23/19Patient InformationPatient InitialsG.Y.Age29SexFemaleChief ComplaintAnnual Comprehensive Health AssessmentHistory of Present Illness (HPI)Denies any present illness7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsDenies any medication prescribed or over the counterAllergiesNo Known Allergies1
Medical HX (PMH)ChildhoodNoneAdultNoneSurgicalNoneOb/GynLMP: 9/22/2019PsychiatricNoneVaccinationsFluDate:Fall 2018PneumovaxDate:not receivedTetanusDate:2016Family HX (specify family member affected/age at death)Mother-Healthy no medical problemsFather-Died age 71- CancerSocial/Environmental HXHTNDMCaMI/CADCVATBRenal dzThyroid dzSuicideAlcoholism-drinks socially one wine glass per weekSubstance abuseBorn in: Los Angeles, CAEducation: UndergraduateOccupation: ASL interpreter Family situation: Siblings and mother liveclose by. Lives with boyfriendTransportation options: CarInsurance: Kaiser, provided by employerNeighborhood: Low crime rate, cleanLanguage/Literacy: English, Armenian, ASLAccess to emerging technologies: YesInterests/Hobbies: Hiking and Bike ridingReview of Systems (ROS)List findings, or check as negative.(If you have a positive finding, then describe its seven attributes inthe HPI or PMH)2
(General)satisfaction; use of birth control methods; HIV exposurenegativeMale G/UDischarge from or sores on penis; testicular pain/massesPatient is FemaleFemale G/UMenarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMPVaginal discharge; itching; sores; lumps Menopause; hot flashes; post-menopausal bleeding;