Comprehensive Health Assessment Form

(50 points)

Health History(5 pts total)

Biographical data: (1 pts)

No name or initial required

Age:________Marital status: ____M_____ S_____Sep. ____Cohab.

Birth date: _____________________Number of dependents: ___________________

Educational level: ________________________Gender: _____F _____ M _____Other

Occupation (current or, if retired, past): ___________________________________­­­­___

Ethnicity/nationality: _____________________

Source of history (who gave you the information and how reliable is that person): _______________________________________________________________________

Present health history: (4 pts)

Current medical conditions/chronic illnesses:

Current medications:

Medication/food/environmental allergies:

Past health history: (10 pts total)

Childhood illnesses: Ask about history of mumps, chickenpox, rubella, ear infections, throat infections, pertussis, and asthma.

Hospitalizations/Surgeries: Include reason for hospitalization, year, and surgical procedures.

Accidents/injuries: Include head injuries with loss of consciousness, fractures, motor vehicle accidents, burns, and severe lacerations.

Major diseases or illnesses: Include heart problems, cancer, seizures, and any significant adult illnesses.

Immunizations (dates if known):

Tetanus _______ Diphtheria ________Pertussis ________ Mumps ________

Rubella _______ Polio _____________ Hepatitis B ______Influenza _______

Varicella ______ Other ____________________________________________

Recent travel/military services: Include travel within past year and recent and past military service.

Date of last examinations:

Physical examination _________Vision ___________Dental ___________

Family History (Genogram) (10 points)

Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any major health issues, and, if indicated, cause and age at death Present as a genogram.

Review of Systems (12 points total) Be sure to ask about symptoms specifically.

General health status (1 pt): Ask about fatigue, pain, unexplained fever, night sweats, weakness, problems sleeping, and unexplained changes in weight.

Integumentary (1 pt):

Skin: Ask about change in skin color/texture, excessive bruising, itching, skin lesions, sores that do not heal, change in mole. Do you use sun screen? How much sun exposure do you experience?

Hair: Ask about changes in hair texture and recent hair loss.

Nails: Ask about changes in nail color and texture, splitting, and cracking.

HEENT (2 pts):

Head: Ask about headaches, recent head trauma, injury or surgery, history of concussion, dizziness, and loss of consciousness.

Neck: Ask about neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the neck.

Eyes: Ask about change in vision, eye injury, itching, excessive tearing, discharge, pain, floaters, halos around lights, flashing lights, light sensitivity, and difficulty reading. Do you use corrective lenses (glasses or contact lenses)?

Ears: Ask about last hearing test, changes in hearing, ear pain, drainage, vertigo, recurrent ear infections, ringing in ears, excessive wax problems, use of hearing aids.

Nose, Nasopharynx, Sinuses: Ask about nasal discharge, frequent nosebleeds, nasal obstruction, snoring, postnasal drip, sneezing, allergies, use of recreational drugs, change in smell, sinus pain, sinus infections.

Mouth/Oropharynx: Ask about sore throats, mouth sores, bleeding gums, hoarseness, change voice quality, difficulty chewing or swallowing, change in taste, dentures and bridges.

Respiratory (1 pt):

Ask about frequent colds, pain with breathing, cough, coughing up blood, shortness of breath, wheezing, night sweats, last chest x-ray, PPD and results, and history of smoking.

Cardiovascular (1 pt.):

Ask about chest pain, palpitations, shortness of breath, edema, coldness of extremities, color changes in hands and feet, hair loss on legs, leg pain with activity, paresthesia, sores that do not heal, and EKG and results.

Breasts (1 pt.): (Remember men have breasts too)

Ask about breast masses or lumps, pain, nipple discharge, swelling, changes in appearance, cystic breast disease, breast cancer, breast surgery, and reduction/enlargement. Do you perform BSE (when and how)? Date of last clinical breast examination, and mammograms and results.

Gastrointestinal (1 pt.):

Ask about changes in appetite, heartburn, gastroesophageal reflux disease, pain, nausea/vomiting, vomiting blood, jaundice, change in bowel habits, diarrhea, constipation, flatus, last fecal occult blood test and colonoscopy and results.

Genitourinary (1 pt.):

Ask about pain on urination, burning, frequency, urgency, incontinence, hesitancy, changes in urine stream, flank pain, excessive urinary volume, decreased urinary volume, nocturia, and blood in urine.

Female/male reproductive (1 pt.):

Both: Ask about lesions, discharge, pain or masses, change in sex drive, infertility problems, history of STDs, knowledge of STD prevention, safe sex practices, and painful intercourse. Are you current involved in a sexual relationship? If yes, heterosexual, homosexual,, bisexual? Number of sexual partners in the last 3 months. Do you use birth control? If yes, method(s) used.

Female: Ask about menarche, description of cycle, LMP, painful menses, excessive bleeding, irregular menses, bleeding between periods, last Pap test and results, painful intercourse, pregnancies, live births, miscarriages, and abortions.

Male: Ask about prostate or scrotal problems, impotence or sterility, satisfaction with sexual performance, frequency and technique for TSE, and last prostate examination and results.

Musculoskeletal (1 pt.):

Ask about fractures, muscle pain, weakness, joint swelling, joint pain, stiffness, limitations in mobility, back pain, loss of height, and bone density scan and results.

Neurological (1 pt.): Ask about pain, fainting, seizures, changes in cognition, changes in memory, sensory deficits such as numbness, tingling and loss of sensation, problems with gait, balance, and coordination, tremor, and spasm.

Psychosocial Profile (10 pts)

Health practices and beliefs/self-care activities:Ask about type and frequency of exercise, type and frequency of self examination, oral hygiene practice (frequency of brushing/flossing), screening examinations (blood pressure, prostate, breast, glucose, etc.)

Nutritional patterns: Ask about daily intake (24 hour recall) and appetite.

Functional Ability: Ask if able to perform activities of daily living such as dressing, bathing, eating, toileting and instrumental activities of daily living like shopping, driving, cooking.

Sleep/rest patterns: Ask about number of hours of sleep per night, whether sleep is restful, naps, and use of sleep aids.

Personal habits (tobacco, alcohol, caffeine, and drugs): Ask about type, amount, and years used.

Environmental history: Identify environment as urban/rural, type of home (apartment, own home, condo)

Family/social relationships: Ask about significant others, individuals in home

Cultural/religious influences: Identify any cultural and religious influences on health.

Mental Health: Ask about anxiety, depression, irritability, stressful events, and personal coping strategies.

Now answer the question below: (3 pts)

Using the instructions below, identify 1 physical strength, 1 psychosocial/cognitive strength, and 1 weakness in either category. State why you think this to be true.

With the information you collected, you can begin developing an idea of a client’s weakness and strengths. What is a strength? This might be that a person’s nutritional status appears to be excellent. It may be that there is no impairment of mobility. They may have lots of friends with them so be socially active. What is a weakness? This might be that a person does have impaired mobility or perhaps imbalanced nutrition – more than or less than body requirements. It might be that they have a communication issue that you note or perhaps seem to have a depressed mood, seem alone/isolated.

2.

Title of Assignment: Comprehensive Health History

Purpose of Assignment: The first part of a health assessment is the history. It is contains critical information about the client. It is important for the nurse to feel comfortable asking all types of questions and to be able to identify the pertinent information for that client. This assignment is a comprehensive health history which would normally be done for a new client to a practice or admission.

Course Competency(s): Identify the foundations of health assessment.

Instructions: Using the provided form to guide the interview, collect as much information as the client is willing to divulge. In a combination of bulleted and narrative formatting, document the information gathered. Try not to be too wordy but, at the same time, be comprehensive in your documentation. Remember this is subjective information and should only be what the client tells you. Avoid making judgments until you determine what the strengths and weaknesses are. Submit this as a word document

Grading Rubric:

See history form.

What can human service professionals do to empower this population?What are some of the barriers faced by this particular population?What programs are dealing effectively with this population?

Need 200 words. This is NOT a paper, just a discussion.i just need the questions answered in regards to human services helping children in need

helpwith10

The assignment is divided into two (2) parts.
In Part I of the assignment (due Week 2), you will first read a book excerpt about critical thinking processes: “The Believing Game and How to Make Conflicting Opinions More Fruitful” at http://www.procon.org/sourcefiles/believinggame.pdf . Next, you will review the Procon.org Website in order to gather information. Then, you will engage in prewriting to examine your thoughts.
Note: In Part II of the assignment (due Week 4), you will write an essay geared towards synthesizing your ideas.

 

Part I – Prewriting : Follow the instructions below for this prewriting activity.  Use complete sentences and adhere to standard rules of English grammar, punctuation, mechanics, and spelling.
1. Select one (1) of the approved topics from the www.procon.org Website and state your position on the issue.
2. From the Procon.org Website, identify three (3) premises (reasons) listed under either the Pro or Con section – whichever section opposes your position.
3.For each of the three (3) premises (reasons) that oppose your position on the issue, answer these “believing” questions suggested by Elbow:

 What’s interesting or helpful about this view?What would I notice if I believed this view?In what sense or under what conditions might this idea be true?”

 

The paper should follow guidelines for clear and organized writing:

 Include an introductory paragraph and concluding paragraph.Address main ideas in body paragraphs with a topic sentence and supporting sentences.Adhere to standard rules of English grammar, punctuation, mechanics, and spelling.

 

Your assignment must follow these formatting requirements:

 Be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides; citations and references must follow APA Style format. Check with your professor for any additional instructions.Include a cover page containing the title of the assignment, the student’s name, the professor’s name, the course title, and the date. The cover page and the reference page are not included in the required assignment page length