Rhinevault-Comprehensive Health Assessment Documentation Form.docx

Advanced Nursing Practice Field Experience
Comprehensive Health Assessment Documentation Form
Date:2/26/2020
Patient Information
Patient Initials CC
Age 52
Sex M
Chief Complaint
Physical
History of Present Illness (HPI)
Annual physical
7 attributes of a symptom: location, quality, quantity/severity, timing, setting,
remitting/exacerbating factors, associated manifestations
Medications
Omeprazole
Atorvastatin
Naproxen
Allergies
NKDA
Medical HX (PMH)
1

Childhood Exploratory laparotomy for internal bleeding.
Appendix removed.
Adult High cholesterol, GERD, arthritis in spine
Surgical Exploratory laparotomy
Ob/Gyn None
Psychiatric None
Vaccinations
Flu Date:
10/2019
Pneumovax Date: Not
received
Tetanus Date: 12/2019
Family HX (specify family member affected/age at death)
Father- heart disease, age at death 88
Social/Environmental HX
 HTN
 DM
 Ca
 MI/CAD
 CVA
 TB
 Renal dz
 Thyroid dz
 Suicide
 Alcoholism
 Substance abuse
Born in: California
Education: Associates degree
Occupation: Police officer
Family situation: Married, no kids
Transportation options: Drives self
Insurance: Insured
Neighborhood: Rural
Language/Literacy: English/Spanish
Access to emerging technologies: Y
Interests/Hobbies: Farming, dogs
 
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;
Negative
3

hematochezia; melena; hemorrhoids;
constipation; diarrhea; food
intolerance
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 Negative
Female
G/U
Menarche; frequency/duration of
menses; dysmenorrhea; PMS
symptoms: bleeding between menses
or after intercourse; LMP
Vaginal discharge; itching; sores;