Health History for Health Assessment
NSG306 Health Assessment:
Health History on Mr. Ricky Ricardo
Jean Bors-Koefoed & Sarah Wright
Baptist College of Health Sciences
Health History
Biographical Data
Date: 05-23-2010
Name: Ricky Ricardo
Gender: Male
Race/Ethnicity: Hispanic
Marital Status: Married
Date of Birth: XX/XX/XX
Occupation: Medical Device Representative
Address: XXX XXXX
XXXXXXXXXXXXXXX
Phone Number: (XXX) XXX-XXXX
Contact Person (relationship to patient): Lucille Ball/wife (XXX) XXX-XXXX
Reason for Seeking Healthcare:
“Providing a Health History for Health Assessment”
History of Present Illness:
Patient does not have a present illness. He is only seeking care for the purpose of providing a health history for the interviewer’s assignment.
Obtaining the history of the presenting illness of a patient is important in determining if the illness is a one-time acute condition, or one of a more chronic nature. If the patient has experienced the same illness or symptoms in the past, it can be helpful to know how the condition was treated and how successful the treatment was, so a current course of therapy can be prescribed effectively. In the case of Mr. Ricardo, because he does not have an illness at the present time, he would not have a history of an illness to provide.
Current Health Status:
Medications (prescribed/over-the-counter): The patient is prescribed Adderral for ADHD. Patient takes 30mg/2x a day. Last dose taken was May 18, 2010. Patient also takes Benadryl when needed.
Medications are important to document because they can sometimes be the cause of what is wrong. Prescribed drugs and over-the-counter drugs can interact with each other and have negative consequences. It is also important to consider dosage of each medication because the dose itself might need to be adjusted because it is causing problems. For this patient, this information can be significant because Adderral has various side-effects that
Health History on Mr. Ricky Ricardo
Jean Bors-Koefoed & Sarah Wright
Baptist College of Health Sciences
Health History
Biographical Data
Date: 05-23-2010
Name: Ricky Ricardo
Gender: Male
Race/Ethnicity: Hispanic
Marital Status: Married
Date of Birth: XX/XX/XX
Occupation: Medical Device Representative
Address: XXX XXXX
XXXXXXXXXXXXXXX
Phone Number: (XXX) XXX-XXXX
Contact Person (relationship to patient): Lucille Ball/wife (XXX) XXX-XXXX
Reason for Seeking Healthcare:
“Providing a Health History for Health Assessment”
History of Present Illness:
Patient does not have a present illness. He is only seeking care for the purpose of providing a health history for the interviewer’s assignment.
Obtaining the history of the presenting illness of a patient is important in determining if the illness is a one-time acute condition, or one of a more chronic nature. If the patient has experienced the same illness or symptoms in the past, it can be helpful to know how the condition was treated and how successful the treatment was, so a current course of therapy can be prescribed effectively. In the case of Mr. Ricardo, because he does not have an illness at the present time, he would not have a history of an illness to provide.
Current Health Status:
Medications (prescribed/over-the-counter): The patient is prescribed Adderral for ADHD. Patient takes 30mg/2x a day. Last dose taken was May 18, 2010. Patient also takes Benadryl when needed.
Medications are important to document because they can sometimes be the cause of what is wrong. Prescribed drugs and over-the-counter drugs can interact with each other and have negative consequences. It is also important to consider dosage of each medication because the dose itself might need to be adjusted because it is causing problems. For this patient, this information can be significant because Adderral has various side-effects that