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 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: Date: Client/Patient Initials:
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HISTORY AND PHYSICAL EXAMINATION Patient Name: Deanna Martinez ID No.: 117232 Room No.: 425 Date of Admission: 05/26/2013 Admitting Physician: Sheila Goodman‚ MD Admitting Diagnosis: Questionable herniated disk Chief Complain: Low back pain‚ right leg pain. HISTORY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain. She said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent
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Health History and Screening of an Adolescent or Young Adult Client Student Name: Biographical Data Patient/Client Initials: Phone No: Address: Birth Date: A Years Sex :Female Birthplace: Marital Status: Single Race/Ethnic Origin: Occupation: High School Student Employer: Unemployed Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability
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[pic] HISTORY AND PHYSICAL EXAMINATION (H&P) Patient Name: Brenda Seggerman Hospital No.: N/A Room No.: N/A Date of Admission: 03/27/- - - - Admitting Physician: Alex Mcclure‚ MD Admitting Diagnosis: Ectopic Pregnancy HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. The patient denies the chance of pregnancy‚ although the patient states that she
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HILLCREST MEDICAL CENTER HISTORY AND PHYSICAL EXAMINATION Patient Name: Emma Parker Hospital No.: 11259 Room No.: 444 Date of Admission: 09/25/2010 Admitting Physician: Sherman Loyd‚ M.D. Admitting Diagnosis: Acute intertrochanteric fracture of right hip. The history below was obtained from the patient and physical examination was performed with her stated verbal understanding and consent. She was alert oriented x3 with reasonable thought content she understood questions
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Health History and Screening of an Adolescent or Young Adult Client Student Name: Date: January 26‚ 2014 Biographical Data Patient/Client Initials: CB Phone No: 602-388-1612 Address: 115 W. Coronodo Road‚ Phoenix‚ AZ 85003 Birth Date: 12/05/98 Age: 15 Sex: M Birthplace: Phoenix Marital Status: Single Race/Ethnic Origin: White Occupation: Student Employer: N/A Financial Status: Aetna Health Insurance Source and Reliability of Informant:
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Admission: 06/22/…. Admitting Physician: Leon Medina‚ MD Internal Medicine Admitting Diagnosis: Stomatitis possibly methotrexate related. Chief Complaint: Swelling of lips causing difficulty swallowing. HISTORY OF PRESENT ILLNESS: This patient is a 57-year-old Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately two weeks ago she developed a respiratory infection for which she received antibiotics
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Individual Client Health History and Examination Grading Criteria | Possible Points | Points Earned | Instructor’s Comments | Health History/Review of Systems: *Information is complete. *Information is appropriate‚ demonstrating understanding of the specified information. * No errors in spelling or grammar. |
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The aim of this assignment will be to select a client cared for on a placement and look at the assessment tools used to provide holistic care for this client. It will examine the various assessments used on this client and discuss the holistic needs of the client. My placement area was with a Community Mental Health Team and so the assessment tool used was the Community Mental Health Team Assessment and Progress Record. Carpenito-Moyet (2005‚ p.231) defined an assessment as “the deliberate and
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population of the U.S. keeps increase to be a diversity nation. As they emerge to one nation‚ they share common concerns about life such as health and quality of life. Providing effective health care to diverse ethnic group‚ cultural minority group‚ need to have proper assessment tool for assessment for their cultural needs‚ beliefs‚ and their traditional health care practice. The Heritage Assessment Tool create effective assessment of background of people include age‚ gender‚ family structure‚ nationality
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