Complete Health History and Examination Assignment

NUR3069- Advanced Health Assessment

Miami Dade College- Medical Campus

I. Biographical data:

Name (Initials only): ________________________________

Age: ________________________________

Gender: M or F ________________________________

Birthplace: ___ (City/Country) ________________________________

Marital Status: ________________________________

Occupation: ________________________________

Race/ ethnic origin: ________________________________

Employer________________________________

Accompanied by, or, significant other: ________________________________

Source and reliability of information: ________________________________

Source of referral________________________________

Reason for seeking care: ________________________________

Present health or HPI (if applicable):

Present Illness (if applicable): ________________________________

Time of onset: ________________________________

Type of onset: ________________________________

Severity: ________________________________

Radiation: ________________________________

Time Relationship: ________________________________

Duration: ________________________________

Course: ________________________________

Association: ________________________________

Source of relief: ________________________________

Source of aggravation: ________________________________

II. Past Medical History (PMH):

General State of Health: ____________________________

Childhood Illnesses: _______________________________

Childhood Vaccinations: ___________________________

Adult Illnesses: ___________________________________

Past Surgeries: _________________________________

Past Hospitalizations: ______________________________

Psychiatric Disorders Diagnosed: _____________________

III. Current Health Status:

Current Medications: (OTC, PRN’s and Prescribed) ______

Allergies: (Food, Meds or Environment) ________________

Drugs: ________________________________

Alcohol: ________________________________

Tobacco: ________________________________

Diet: (24-hour totals) _________________________________

Screening tests: _________________________________

Sleep patterns: ________________________________

Exercise & Leisure activities: ___________________________

Environmental hazards: ________________________________

Safety measures: _ ____________________________________

IV. Family History:

Known genetic problems: ________________________________

Heart disease: ________________________________

Allergies: ________________________________

Hypertension: ________________________________

Asthma: ___________________

Stroke: _____________________

Obesity: ___________

Diabetes: ________________________________

Alcoholism: ________________

Blood disorders: _______________

Mental illness: ________________

Breast cancer: _________________

Kidney disease: _______________

Cancer (other): __________________

Seizure disorder: _______________

Sickle Cell: ___________________

Arthritis:.______________

V. Genogram: (Attached)

VI. Review of Systems: (3 negatives needed)

General: _____________

Skin___________________

Neurological: ________________________________

Eyes: ________________________________

Ears: ________________________________

Nose/Sinuses: _________________________________________________________________

Mouth/Throat: ________________________________________________________________

Neck: _______________________________________________________________________

Respiratory: __________________________________________________________________

Chest/Breast: _________________________________________________________________

Cardiac: _____________________________________________________________________

Gastrointestinal: _______________________________________________________________

Genitourinary: _________________________________________________________________

Peripheral vascular: _____________________________________________________________

Musculoskeletal: _______________________________________________________________

Hematological: ________________________________________________________________

Endocrine: ___________________________________________________________________

Psychiatric: ___________________________________________________________________

Physical Examination:

Vital Signs:

Temperature (F°): _____________ (Oral/tympanic/rectal) Pulse: __________________ (artery?)

Resp Rate _________________ Weight: ________________ Height: ________________

BMI: ______________Physical appearance: ________________

Level of Consciousness: ___________________ Facial features: ____________________ General: ____________________________________________________________________

Skin: ______________________________________________________________________

Neurological: ________________________________________________________________

Eyes: _______________________________________________________________________

Ears: _______________________________________________________________________