Advanced Nursing Practice Field Experience
Comprehensive Health Assessment Documentation Form
Date:__12/23/18________
Patient Information
Patient Initials
CM
Age
20
Sex
M
Chief Complaint
Physical assessment
History of Present Illness (HPI)
No illness at this time
7 attributes of a symptom: location, quality, quantity/severity, timing, setting,
remitting/exacerbating factors, associated manifestations
Medications
none
Allergies
none
Medical HX (PMH)
1
Childhood
none
Adult
none
Surgical
none
Ob/Gyn
none
Psychiatric
none
Vaccinations
Flu
Date:
10/13/18
Pneumovax
Date:
unknown
Tetanus
Date:
unknown
Family HX (specify family member affected/age at death)
none
Social/Environmental HX
HTN
DM
Ca
MI/CAD
CVA
TB
Renal dz
Thyroid dz
Suicide
Alcoholism
Substance abuse
Born in: Florida
Education: High School and
Firefighter/EMT school
Occupation: Firefighter/EMT
Family situation: single
Transportation options: owns vehicle
Insurance: yes
Neighborhood: good
Language/Literacy: English
Access to emerging technologies:
going back to school for fire
certifications.
Interests/Hobbies: works out, hunts
2
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
negative
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
negative
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
G/I
Appetite Δ; jaundice; nausea/emesis;
dysphagia; heartburn; pain;
belching/flatulence; Δ in bowel habits;
hematochezia; melena; hemorrhoids;
constipation; diarrhea; food
intolerance
Negative
Last BM 12/23/18
Urinary
Frequency; nocturia; urgency; dysuria;
negative
3
hematuria; incontinence
MALES
: caliber of urinary stream;
hesitancy; dribbling
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
negative
Female
G/U
Menarche; frequency/duration of
menses; dysmenorrhea; PMS
symptoms: bleeding between menses
or after intercourse; LMP
Vaginal discharge; itching; sores;
lumps Menopause; hot flashes; post-
menopausal bleeding;
negative
Peripheral
Vascular
Claudication; leg cramps; varicose
veins; hx of blood clots
negative
Musculo-
skeletal
Muscle or joint pain; joint stiffness
negative
Neuro
Syncope; seizures; weakness;
paralysis; numbness/tingling; tremors;
