Advanced Nursing Practice Field Experience
Comprehensive Health Assessment Documentation Form
Date:___4-27-20
_______
Patient Information
Patient Initials
R.O.
Age
50 yrs. old
Sex
male
Chief Complaint
“Here for a Comprehensive Health Assessment”
History of Present Illness (HPI)
No specific patient complaints
7 attributes of a symptom: location, quality, quantity/severity, timing, setting,
remitting/exacerbating factors, associated manifestations
Medications
Prescription
none
Over the Counter
Prilosec OTC – 1 tablet per day
Allergies
No known drug or
environmental allergies
Medical HX (PMH)
Childhood
Denies childhood illnesses
Adult
Denies any illness or medical problems. Patient does take
OTC medication daily for gastric reflux
Surgical
B Lasix Eye surgery-1997 & Vasectomy-2004
Ob/Gyn
Not applicable – Patient is male
Psychiatric
Denies psychiatric history
Vaccinations
Flu
Date: denies
Pneumovax
Date: denies
Tetanus
Date: >7-10 years ago
Family HX (specify family member affected/age at death)
1
Father deceased at age 70-heart failure
Mother – living with HTN
Brother – living with HTN
Sister deceased at age 40-Breast Cancer with bone metastasis
Social/Environmental HX
HTN
DM
Ca
MI/CAD
CVA
TB
Denies all
above
Renal dz
Thyroid dz
Suicide
*Alcoholism
*Substance abuse
Denies renal disease,
thyroid disease, suicidal
thoughts or attempts.
*Patient states averages
3-7 alcohol drinks per
week.
*Patient states smoked
for a total of 5 years 25
years ago, but denies
substance abuse
Born in: Huntsville, Alabama in 1970
Education: High School Graduate
Occupation: Appliance Salesman
Family situation:
Married, 2 children
Transportation options: Patient has private
vehicle, but drives company vehicle to work
Insurance: has medical/dental insurance,
also confirms home/car insurance coverage
Neighborhood: Patient is a land & home
owner in suburb county area.
Language/Literacy: English speaking,
average literacy
Access to emerging technologies: yes,
patient if familiar with and uses technology
daily
Interests/Hobbies:
Hunting and Fishing
2
Interview Questions for Social Determinants:
Economic Stability
:
Can you tell me about your job?
How far do you have to travel for your job?
Can you tell me where you live?
Do you own your house?
Do you have a mortgage & insurance on your home?
Are you able to make those payments appropriately and on time?
Education
:
What is your highest level of education?
Social & Community Context
:
Tell me about your support system. Who are they?
Are you able to spend time with family & friends?
Do you live in a rural or urban community?
Do you have access to community resources?
Health & Healthcare
:
Do you have a primary care physician (or access to one)?
When was your last physical?
Where do you go for urgent or emergency care?
