HealthHistoryTemplatewithNotes.docx
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NR302 Required Health History Assessment – 100 points
Student Name:
1. Biographical Data
Name: Only initials Address:
Phone:Gender:
Birth Date: Birthplace:
Age: Marital Status:
Occupation: Religion:
Race/Ethnic origin: Employer:
Source and Reliability:
Reason for seeking care:
Present Health or History of Present Illness (HPI):
Perception of Own Health:
Do not put “negative for any of these sections. Be specific. Ex. Patient denies history or measles, mumps, etc. Use your book for questions.
Past Health:
Childhood illness:
Serious/Chronic illness:
Accident/Injuries:
Hospitalizations:
Operations:
Obstetric History: G: T: P: A: L:
Course of pregnancy:
Immunizations:
Last examination date:
Allergies:
Reaction:Any treatment:
Current Medications:
Family History
You ma provide a genogram or 1 paragraph that comments on at least 3 generations. Include relationship to patient, ages of family members, age of death, medical conditions etc.
Utilize your book page 50 or lab manual page 31 for Review of Systems subjective questions. Do not include physical assessment findings in this section.
General Overall Health State:
Height Weight BMI
Skin:
Hair:
Nails:
Head:
Eyes:
Ears:
Nose and Sinuses:
Mouth and Throat:
Breast:
Respiratory System:
Cardiovascular System:
Peripheral Vascular System:
Gastrointestinal System:
Urinary System:
Genital System:
Sexual Health:
Musculoskeletal System:
Neurologic System:
Hematologic System:
Endocrine System:
Developmental considerations Consider Erikson stages of development. 1 paragraph
Cultural considerations How does culture impact or not impact the patient’s health beliefs and wellness. 1 paragraph
Psychosocial considerations 1 paragraph
Collaborative resources that could be recommended for any teaching/learning needs the client may have (Consider the client’s age as well as any cultural, lifespan, or psychosocial concerns. Think about Community, Family, Groups, and/or Health Care System resources)
1 paragraph. Do not just list resources but tell us why it would be helpful.
REFLECTION – 40 points
Review questions on national rubric and answer each one for credit.
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