Health Assessment
Running head: HEALTH ASSESSMENT
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Health History Paper Jane Doe Norfolk State University
HEALTH ASSESSMENT HEALTH ASSESSMENT
2
Date of Interview:
07/13/11
1. BIOGRAPHICAL DATA A.A., a 37 year old African male, present today for an annual health assessment. Patient is married and has three children. Patient states patient states “I am happy with the way things are with me, and I am taking good care of myself, I don’t smoke or drink.” Patients states he is healthy and hardly visits the hospital unless when he takes the kids or for medical examination. 2. PAST HEALTH HISTORY: Patent reports chicken pox as the only childhood illness he could remember, and no adult illness or any psychiatric illness. Patients states that he was involved in an accident when he was six years old but no lasting damage was done, and that he has not had any operations before and has only had one hospitalizations for chest pain. Patient states “I was so scared and since then I’ve not missed my annual physicals”. (Pg. 781, incorporate childhood illnesses, accidents, chronic illnesses, hospitalizations, obstetric history, immunizations, last exam, allergies, current meds.) 3. FAMILY HISTORY: Pt states that father and mother are still alive and healthy, father is 80 years old and mother is 70 years old. No disability with the client. Patients states that the wife is alive, hale and healthy, and he has three children, they all live in a peaceful environment. Client states “I go to work Monday to Friday, and spend my weekends with my family and God.” Patient is presently working but decline to mention where.
HEALTH ASSESSMENT 4. REVIEW OF SYSTEMS (ROS): This example shows minimal requirements (see pages 782-783 of your text for complete examples.) a. General: Patient was alert and oriented to person, place and time during assessment. Able to attend cooperatively with examiner with appropriate eye contact, speech slightly impaired. b. Skin, Hair, and Nails: Dark skinned,
1
Health History Paper Jane Doe Norfolk State University
HEALTH ASSESSMENT HEALTH ASSESSMENT
2
Date of Interview:
07/13/11
1. BIOGRAPHICAL DATA A.A., a 37 year old African male, present today for an annual health assessment. Patient is married and has three children. Patient states patient states “I am happy with the way things are with me, and I am taking good care of myself, I don’t smoke or drink.” Patients states he is healthy and hardly visits the hospital unless when he takes the kids or for medical examination. 2. PAST HEALTH HISTORY: Patent reports chicken pox as the only childhood illness he could remember, and no adult illness or any psychiatric illness. Patients states that he was involved in an accident when he was six years old but no lasting damage was done, and that he has not had any operations before and has only had one hospitalizations for chest pain. Patient states “I was so scared and since then I’ve not missed my annual physicals”. (Pg. 781, incorporate childhood illnesses, accidents, chronic illnesses, hospitalizations, obstetric history, immunizations, last exam, allergies, current meds.) 3. FAMILY HISTORY: Pt states that father and mother are still alive and healthy, father is 80 years old and mother is 70 years old. No disability with the client. Patients states that the wife is alive, hale and healthy, and he has three children, they all live in a peaceful environment. Client states “I go to work Monday to Friday, and spend my weekends with my family and God.” Patient is presently working but decline to mention where.
HEALTH ASSESSMENT 4. REVIEW OF SYSTEMS (ROS): This example shows minimal requirements (see pages 782-783 of your text for complete examples.) a. General: Patient was alert and oriented to person, place and time during assessment. Able to attend cooperatively with examiner with appropriate eye contact, speech slightly impaired. b. Skin, Hair, and Nails: Dark skinned,