HEALTH HISTORY. 3. Refer to list of common medical abbreviations guide for appropriate terminology.



Similar documents
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

PATIENT HISTORY FORM

CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850

Cardiac Rehabilitation

Emory Eye Center New Patient Questionnaire

MEDICAL HISTORY AND SCREENING FORM

NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute

JAMES PETROS, M.D., INC. PHONE: (408) FAX: (408)

NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

Patient Information Form Pain Management Center at Phoebe

Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Primary Care Physician: Pharmacy: Pharmacy Phone #:

Caring for the Client with Heart Failure

Cardiac Rehabilitation. Exercise and Education Program

The following document includes information about:

Managing Acute Side Effects of Colorectal & Anal Radiation Therapy

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE

Marilyn Borkgren-Okonek, APN, CCNS, RN, MS Suburban Lung Associates, S.C. Elk Grove Village, IL

PLEASE PRINT LEGIBLY

The Impact of Alcohol

Patient Questionnaire for Men

Insomnia affects 1 in 3 adults every year in the U.S. and Canada.

Clinical Care Program

First Name. Profession. Weight lbs. Weight 1 year ago lbs. Min. Adult Weight lbs. at age Maximum Weight lbs. at age

Addiction Medical Clinic LLC

Mountain View Natural Medicine PATIENT REGISTRATION FORM PATIENT INFORMATION

SPINE PATIENT HISTORY FORM

CONSULTATION & CONSENT FORMS p. 1 of 5 C J HERBAL REMEDIES, INC. ********************************************************************************

Women s Continence and Pelvic Health Center

HEALTH RISK ASSESSMENT (HRS) QUESTIONNAIRE

NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH Phone: Fax:

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:

HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION

Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD

General Internal Medicine Clinic New Patient Questionnaire

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

COPD - Education for Patients and Carers Integrated Care Pathway

PARTNERS IN PEDIATRIC CARE. Intake and History for Mental Health Referral

Notice of Privacy Practices

Managing Acute Side Effects of Pelvic Radiation for Gynaecological Cancers

BASIC INFORMATION ABOUT HIV, HEPATITIS B and C, and TUBERCULOSIS Adapted from the CDC

Dallas Neurosurgical and Spine Associates, P.A Patient Health History

CAMARILLO AQUATICS AND REHABILITATION SERVICES

Living With Congestive Heart Failure

PATIENT INFORMATION INSURANCE INFORMATION

Cardiovascular Disease Risk Factors

GrapeGate v1.0

Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:

LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:

Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX Phone-214) Fax-214)

Cardiac Rehabilitation

Reintegration. Recovery. Medication-Assisted Treatment for Alcohol Dependence. Reintegration. Resilience

Communicating Effectively with Healthcare Providers

Managing Acute Side Effects of Prostate Radiation Therapy

Diabetes Self-Management Questionnaire

FAIRBANKS PHYSICAL THERAPY

Borgess Diabetes Center PATIENT REGISTRATION/DEMOGRAPHICS

St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?

NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone address

Full name DOB Age Address Phone numbers (H) (W) (C) Emergency contact Phone

After Your Gastrectomy

THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History

Clinical Clerkship Curriculum Family Medicine

es of Urinary Incontinence:

BEST U INSTRUCTOR: DR AMY WALTERS, PHD

Community Internal Medicine of Athens 1500 Oglethorpe Avenue Suite 200D Athens, GA Phone: (706) Fax: (706)

What to Expect While Receiving Radiation Therapy for Prostate Cancer

Congestive Heart Failure

Adult Information Form Page 1

Bladder Control Does Matter

INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM

REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:

Quality Measures for Long-stay Residents Percent of residents whose need for help with daily activities has increased.

PEDIATRIC MEDICAL HISTORY FORM

What Causes Cancer-related Fatigue?

What to Do When Receiving Radiation Therapy to the Pelvis

Daily Habits and Urinary Incontinence

Preventive Care Recommendations THE BASIC FACTS

General SD Initial Visit Patient Questionnaire Men s Health Center LAST NAME: FIRST NAME: DOB:

New Patient Intake Form

Coping With Stress and Anxiety

You will be secure, because there is hope. Job 11:18

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico (575) Fax: (575)

Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach

LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)

Overview of Urinary Incontinence in the Long Term Care Setting

Bladder Health Promotion

Medical Massage Client Intake Form Medical Massage Client Intake Form

Memorial Hospital Sleep Center. Rock Springs, Wyoming Sleep lab Phone: (Mon - Wed 5:00 pm 7:00 am)

NEW PATIENT INFORMATION FORM

Patient Name: Patient X Date of Birth: April 15, 1954 Age: 54 Start Date: May 20, 2008

What you should know about treating your pain with opioids. Important information on the safe use of opioid pain medicine.

PATIENT HEALTH QUESTIONNAIRE: Urology

MILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE

Bladder Health Promotion

SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D]

PATIENT INTAKE / HISTORY FORM PATIENT INFORMATION

How To Write A Recipe Card

Title. Nationality.

Holistic Chiropractic and Craniosacral Therapy. Rosewood Family Healing Center - Dr. Maura Moynihan

Transcription:

HEALTH HISTORY PURPOSE To provide the student with the opportunity to combine interviewing and documenting skills in one assignment. The student will, for a selected adult patient, complete a health history and perform a health risk assessment and document using a nurse s progress note format. PREPARATION: 1. READ THE ASSESSMENT FORM BEFORE THE EXPERIENCE. 2. Review Lewis, pp. 39-52. 3. Refer to list of common medical abbreviations guide for appropriate terminology. CRITERIA: 1. Respond to each item on the Health History. 2. Document current and accurate information on the assignment form using appropriate medical abbreviations and terminology. 3. Complete Health Risk Assessment page. 4. Write a Nursing Progress Note incorporating identified health risks and nursing plan that addresses the risk behaviors including pertinent information from the interview. Assume that other staff may not have access to this information. ASSIGNMENT AND DUE DATE: One written Health History, Health Risk Assessment and Nursing Progress Note will be submitted to the student s clinical faculty within one week following this clinical experience.

HEALTH HISTORY Use both patient interview and medical record for gathering data. Student Name: Date: GENERAL INFORMATION Patient Initials: Sex: M F Age: DOB: Health care insurance: Source(s) of information: History of present condition/illness/surgery: Patient s understanding of current condition: Past health/medical problems: Medications currently prescribed: Nonprescription medications used and frequency: Health maintenance, health promotion practices, healing modalities and home remedies: History of family health/illness (DM, cancer, HTN, CVA, MI, communicable diseases, emotional illness):

Allergies (include foods, medications, environmental sources, latex, etc.) SUBSTANCE REACTION Substance use: Number of cigarettes/day: Other tobacco/day: Number of years smoked: Amount of caffeinated beverages/day: Amount/type of alcoholic drinks/day: Other substances: Oxygenation Assessment Chest Pain/Palpitations: (frequency precipitating/alleviating factors) Cough, Sputum or Dyspnea: Distance patient can walk without resting: (Is patient limited by SOB, claudication, fatigue, angina) Number of pillows patient sleeps with at night: Nocturia: Rest/Sleep/Comfort Assessment Hours worked/day: Hours of sleep/night: Rest periods/naps: Yes No Describe:

Measures to aid sleep (include medications): Sleep problems: Pain, discomfort: If yes, describe (include if acute or chronic in nature): Activity Assessment Type and amount of activity/exercise: Gait: Muscle Strength: Musculoskeletal discomfort or limitation: Assistive Devices: Ability to care for self: Nutrition Assessment 24 hour recall of typical day. Food Fluid INTAKE BREAKFAST LUNCH DINNER SNACKS Usual times of meals at home

Dietary restrictions/dislikes/difficulty: Appetite: Recent weight and/or appetite changes: Ability to feed self: Dentition: Symptoms (nausea, vomiting, pain, emesis, bleeding): Bowel Elimination Assessment Typical bowel elimination pattern: Appearance of stool: Continence: Symptoms (diarrhea, blood, hemorrhoids, pain): Urinary Elimination Assessment Typical daily voiding pattern: Appearance of urine: Continence: Symptoms (dysuria, hematuria, anuria):

Safety and Security Assessment Hearing: Sight: Aids: Orientation to: Person: Place: Time: Environmental history (exposure to domestic/occupational/recreational substances; noise, chemicals, infectious agents; financial concerns) Higher Level Needs Educational Level: Occupation: Ability to speak and understand: Type and Place of Residence: Student: Yes No Employed: Yes No / Retired: Yes No Religion: Present emotional state: Usual emotional state: Symptoms (anxiety, stress, depression, grief):

Love and Belonging Primary support: Family composition: (do not write down names) Household members relationships Symptoms (adequacy of relationships and social support, domestic violence): Sexuality (partner, STD exposure and protection, contraception): Recognition/Esteem Hobbies: Volunteer work: Other pertinent data:

HEALTH RISK ASSESSMENT Based on the data gathered in the Health History, identify: 1. Risk behavior(s): 2. Probable consequences of continuing this behavior for this patient: 3. Circle the patient s stage of readiness for change of this risk behavior, using the information contained in the chronic illness conference guide. 1. Pre-contemplation 2. Contemplation 3. Determination/ Planning 4. Action 5. Maintenance 6.Relapse Support this stage selection with patient information (e.g. patient statements or patient activities r/t the risk behavior): 4. Recommended Plan of Action: EXAMPLE 1. Risk behavior(s): sedentary lifestyle, high sodium, high fat diet, cigarette smoking 2. Probable consequences of continuation of this behavior for this patient: hypertension, coronary artery disease, MI, CVA, cancer 3. Circle the patient s stage of readiness for change of this risk behavior, using the information contained in the chronic illness conference guide. Pre-contemplative /Contemplative / Planning / Action / Maintenance / Relapse 4. Refer to dietician; teach benefits of regular exercise; provide smoking cessation materials.

NURSING PROGRESS NOTE

2024 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information