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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate:__12/23/18________Patient InformationPatient InitialsCMAge20SexMChief ComplaintPhysical assessmentHistory of Present Illness (HPI)No illness at this time7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsnoneAllergiesnoneMedical HX (PMH)1
ChildhoodnoneAdultnoneSurgicalnoneOb/GynnonePsychiatricnoneVaccinationsFluDate: 10/13/18PneumovaxDate:unknownTetanusDate:unknownFamily HX (specify family member affected/age at death)noneSocial/Environmental HXHTNDMCaMI/CADCVATBRenal dzThyroid dzSuicideAlcoholismSubstance abuseBorn in: FloridaEducation: High School and Firefighter/EMT schoolOccupation: Firefighter/EMTFamily situation: singleTransportation options: owns vehicleInsurance: yesNeighborhood: goodLanguage/Literacy: EnglishAccess to emerging technologies: going back to school for fire certifications.Interests/Hobbies: works out, hunts2
Review of Systems (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; scotomanegativeEarsHearing Δ; tinnitus; earaches; infections; dischargenegativeNose/SinusesColds; congestion; discharge; itching; hay fever; nosebleedsnegativeThroatBleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarsenegativeNeckLumps; 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; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intoleranceNegativeLast BM 12/23/18UrinaryFrequency; nocturia; urgency; dysuria;negative3
hematuria; incontinenceMALES: caliber of urinary stream; hesitancy; dribblingG/U (General)Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposurenegativeMale G/UDischarge from or sores on penis; testicular pain/massesnegativeFemale 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; negativePeripheralVascularClaudication; leg cramps; varicose veins; hx of blood clotsnegativeMusculo-skeletalMuscle or joint pain; joint stiffnessnegativeNeuroSyncope; seizures; weakness; paralysis; numbness/tingling; tremors;