Advanced Nursing Practice Field Experience
Comprehensive Health Assessment Documentation Form
Date:
Patient Information
Patient Initials
Age
Sex
Chief Complaint
Patient reports having discomfort in left hip when doing physical
activities, otherwise no current complaints. Patient reports no medical
history. Patient reports that he is followed by a physician and has
regular yearly check-ups.
History of Present Illness (HPI)
Patient reports no medical history of illnesses.
7 attributes of a symptom: location, quality, quantity/severity, timing, setting,
remitting/exacerbating factors, associated manifestations
Medications
No medications.
Allergies
No known drug or food
allergies.
1
Medical HX (PMH)
Childhood
No medical history.
Adult
No medical history.
Surgical
No surgical history.
Ob/Gyn
N/A
Psychiatric
No medical history.
Vaccinations
Flu
Date: Oct.
2018
Pneumovax
Date: N/A
Tetanus
Date: Unknown—
patient states is up
to date
Family HX (specify family member affected/age at death)
Father: No medical history—Alive
Mother: No medical history—Alive
Sister: No medical history—Alive
Sister: No medical history—Alive
Social/Environmental HX
HTN-No
DM-No
Ca-No
MI/CAD-No
CVA-No
TB-No
Renal dz-No
Thyroid dz-No
Suicide-No
Alcoholism-No
Substance abuse-
No
Born in:
Edmond, Oklahoma
Education:
Bachelors Degree
Occupation:
Software Architect
Family situation:
Married, currently
lives in single family home.
Transportation options:
Owns own
care
Insurance:
Health Insurance through
occupation
Neighborhood:
Lives in suburbs
2
Language/Literacy:
English, patient
is able to read and write
Access to emerging technologies:
Yes.
Interests/Hobbies:
Cooking, being
outside, playing and listening to
music
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
-
Skin
Rash; lumps; sores; itching; dryness;
color change; Δ in hair/nails
-
Head
Headache; head injury; dizziness
-
Eyes
Vision Δ; corrective lenses; last eye
exam; pain; redness; excessive
tearing; double vision; blurred vision;
scotoma
-
Ears
Hearing Δ; tinnitus; earaches;
infections; discharge
-
Nose/
Sinuses
Colds; congestion; discharge; itching;
hay fever; nosebleeds
-
Throat
Bleeding gums; dentures; last dental
3
exam; sore tongue; dry mouth; sore
throats; hoarse
-
Neck
Lumps; swollen glands; goiter; pain;
neck stiffness
-
Breasts
Lumps; pain; discomfort; nipple
discharge
-
Pulmonar
y
Cough—productive/non-productive;
hemoptysis; dyspnea; wheezing;
pleuritic pains
-
Cardiac
Chest pain or discomfort; palpitations;
dyspnea; orthopnea; PND; edema
-
G/I
Appetite Δ; jaundice; nausea/emesis;
dysphagia; heartburn; pain;
belching/flatulence; Δ in bowel habits;
hematochezia; melena; hemorrhoids;
constipation; diarrhea; food
intolerance
-
Urinary
Frequency; nocturia; urgency; dysuria;
hematuria; incontinence
MALES
: caliber of urinary stream;
hesitancy; dribbling
-
G/U
(General)
Sexual habits; interest; function;
satisfaction; use of birth control
