Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate:__1/6/2020________Patient InformationPatient InitialsJ.M.Age24SexFChief ComplaintWellness physicalHistory of Present Illness (HPI)No current illness7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsNoneAllergiesPeanutsNKMAMedical HX (PMH)1
ChildhoodNoneAdultNoneSurgicalNoneOb/GynG1P1, 1 NSVDPsychiatricNoneVaccinationsFluDate:10/2019PneumovaxDate:n/aTetanusDate:2019Family HX (specify family member affected/age at death)Paternal grandmother brca 2 positive breast cancer still living age 77Mother and sister alcoholism both still living ages 47 and 21 respectivelySocial/Environmental HXHTNDMCaMI/CADCVATBRenal dzThyroid dzSuicideAlcoholismSubstance abuseSmokes ½ PPD x 2yearsBorn in: USEducation: attending collegeOccupation: college studentFamily situation: lives with spouse and sonTransportation options: privateInsurance:privateNeighborhood: safe/rural communityLanguage/Literacy: English, appropriate for college attendeeAccess to emerging technologies: adequate access to internet etc2
Interests/Hobbies: school, appropriate for age and situationReview 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; feversNo recent unintentional weight changes, denies fatigue or feversSkinRash; lumps; sores; itching; dryness; color change; Δ in hair/nailsSkin free of rashes, sores,denies itching or dryness, no changes in hair or nailsHeadHeadache; head injury; dizzinessDenies headache or dizziness, no history of head injury, no obvious deformitiesEyesVision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotomaNo recent vision changes, wear glasses, last eyes exam June of 2019, deniesblurred or double vision. No redness or tearing noted. No signs of eye infections or needs for further follow up or change of prescription warranted at this timeEarsHearing Δ; tinnitus; earaches; infections; dischargeDenies hearing changes, ringing, or pain in ears. 3
No discharge noted.Nose/SinusesColds; congestion; discharge; itching; hay fever; nosebleedsRecent cold with mild head congestion x2 days, no discharge noted. No nosebleeds or hay feverThroatBleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarseDenies bleeding gums, sore throat or tongue. No hoarseness noted. Last dental exam last year.NeckLumps; swollen glands; goiter; pain; neck stiffnessDenies neck pain or stiffness. No swollen glands or lymph nodes noted. Neck movement wnl.