Health History and Screening Older Adult
Health History and Examination
Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems
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Student Name: Lisa Greenspon | Date: July 21, 2013 | * Client/Patient Initials: MS | Sex: F | Age: 96 | Occupation of Client/Patient: retired bookkeeper | Health History/Review of Systems(Complete and systematic review of systems) | Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications):Patient denies headaches, numbness, tingling, convulsions, tremors, difficulty speaking, or difficulty swallowing. Patient does not take any high risk medications. Has complaints of mild weakness and fatigue. States she fell in her kitchen late one night and bumped her head on the laundry room door. States she did not feel dizzy, just tripped over a kitchen chair with her walker. Patient takes no high risk medications. Called 911 for assistance but refused to go to the hospital for evaluation. | Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Patient denies head or neck pain at this time. No complaint of headache. No complaints of neck soreness or neck pain. Denies any past surgeries of head or neck. She denies lumps or swelling in her head or neck. Patient takes no high risk medications. | Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications): Patient wears reading glasses.
Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems
Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include relevant data for your client.
Student Name: Lisa Greenspon | Date: July 21, 2013 | * Client/Patient Initials: MS | Sex: F | Age: 96 | Occupation of Client/Patient: retired bookkeeper | Health History/Review of Systems(Complete and systematic review of systems) | Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications):Patient denies headaches, numbness, tingling, convulsions, tremors, difficulty speaking, or difficulty swallowing. Patient does not take any high risk medications. Has complaints of mild weakness and fatigue. States she fell in her kitchen late one night and bumped her head on the laundry room door. States she did not feel dizzy, just tripped over a kitchen chair with her walker. Patient takes no high risk medications. Called 911 for assistance but refused to go to the hospital for evaluation. | Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Patient denies head or neck pain at this time. No complaint of headache. No complaints of neck soreness or neck pain. Denies any past surgeries of head or neck. She denies lumps or swelling in her head or neck. Patient takes no high risk medications. | Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications): Patient wears reading glasses.
References: Bell, F. C. (1990). The External Eye Examination. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK218/ Chandrasekhar, A., Pickleman, J., & Klamut, M. (). Liver: Percussion. Retrieved from http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/pd/pstep48.htm Chandrasekhar, A., & Stankiewicz, J. (2006). Screening Physical Exam. Retrieved from http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/pd/pstep18.htm Goldberg, C. (2008). The Neurological Examination. Retrieved from http://meded.ucsd.edu/clinicalmed/neuro2.htm SBAR TEMPLATE – to submit issues of concern to NNLC. (). Retrieved from http://www.ihs.gov/NNLC/documents/resources/SBARTEMPLATE.pdf Thyroid Examination. (). Retrieved from http://www.osceskills.com/e-learning/subjects/thyroid-examination/ Wikipedia. (2013). In Fremitus. Retrieved March 13, 2013, from http://en.wikipedia.org/wiki/Fremitus Wikipedia, (2013). In Parasternal Heave. Retrieved June 2, 2013, from http://en.wikipedia.org/wiki/Parasternal_heave