NRS434V
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: StudentNeesha
Date: 6/4/15
Client/Patient Initials: J.
Sex: Female
Age: 64
Occupation of Client/Patient: Retired
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 reports stress headaches once a week in the last 3 months. During birth of her daughter 45 years age patient reports she had convulsions. Head was pounding pink, purple, and blue lights. Once on the elevator hand started shaking she remembers nothing else.
Toxemia when pregnant, big baby collar bone broken during birth.
Right hand and bilateral feet tingle. Occurs once a day (patient is a diabetic). Hands wrist and ankles swell when cleaning. Ankles stay swollen. Patient refuses to take medicine, reports doctor wrote her a prescription for metformin but she told the doctor “No, I will control with my diet.” Patient vitamin D level 22, MD sent her to a special place to jump start her Vitamin D level. Patient received 10 pills at a cost of $55, patient reports they made her sick and she only took 3 pills and will not take any pills.
Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Patient reports neck pain that radiates to shoulder rarely occurs last episode 6 months ago.
Eyes (eye pain, blurred vision, history of crossed eyes,
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: StudentNeesha
Date: 6/4/15
Client/Patient Initials: J.
Sex: Female
Age: 64
Occupation of Client/Patient: Retired
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 reports stress headaches once a week in the last 3 months. During birth of her daughter 45 years age patient reports she had convulsions. Head was pounding pink, purple, and blue lights. Once on the elevator hand started shaking she remembers nothing else.
Toxemia when pregnant, big baby collar bone broken during birth.
Right hand and bilateral feet tingle. Occurs once a day (patient is a diabetic). Hands wrist and ankles swell when cleaning. Ankles stay swollen. Patient refuses to take medicine, reports doctor wrote her a prescription for metformin but she told the doctor “No, I will control with my diet.” Patient vitamin D level 22, MD sent her to a special place to jump start her Vitamin D level. Patient received 10 pills at a cost of $55, patient reports they made her sick and she only took 3 pills and will not take any pills.
Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Patient reports neck pain that radiates to shoulder rarely occurs last episode 6 months ago.
Eyes (eye pain, blurred vision, history of crossed eyes,
References: Casey, J. (2015, June 3). (T. Neesha , Interviewer) Center for Disease Control and Prevention CDC. (2015, March 19). Retrieved from Center for Disease Control and Prevention : http://www.cdc.gov/diabetes/living/eatright.html