Course Project Milestone #1: Health History Form
Chamberlain College of Nursing NR305 Health Assessment
Course Project Milestone #1: Health History Form
For Use July 18
Your Name: Date:
Your Instructor’s Name:
Directions : Refer to the Milestone 1: Health History guidelines and grading rubric found on the Week 1: Milestone 1 Assignment page. This assignment is worth 225 points. Clarity of writing is worth 20 of the 225 points.
Type your answers on this form. Click Save as and save the file with the assignment name and your last name, for example, NR305_Milestone1_Form_Smith. When you are finished, submit the form by the deadline by using the Submit button on the assignment page. Post questions in the Q & A Forum or contact your instructor if you have questions about this assignment.
Disclaimer : The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do not need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.” If the client fails to disclose answers to several items, you will need to find another client who is willing to share.
Note: Completing this assignment on yourself will result in a 20% penalty deduction being applied.
| BIOGRAPHICAL DATA (15 points) | |
| Date: | |
| Initials: | |
| Age: | |
| Date of birth: | |
| Birthplace: | |
| Gender: | |
| Marital status: | |
| Race: | |
| Religion: | |
| Occupation: | |
| Health insurance: | |
| Source of information: | |
| Reliability of source of information: | |
| PRESENT HEALTH HISTORY/ILLNESS (20 points) | |
| Reason for seeking care: | |
| Health patterns: | |
| Health goals: | |
| HEALTH BELIEFS AND PRACTICES (15 points) | |
| Beliefs and practices: | |
| Factors influencing healthcare decisions: | |
| Related traits, habits or acts: | |
| MEDICATIONS (20 points) (Please refer to your assignment guidelines.) | |
| Prescription medications: | |
| Over-the-counter medications: | |
| Herbals: | |
| PAST HISTORY (20 points) | |
| Childhood diseases: | |
| Immunizations: | |
| Allergies: | |
| Blood transfusions: | |
| Major illnesses: | |
| Injuries: | |
| Hospitalizations: | |
| Labor and deliveries: | |
| Surgeries: | |
| Use of alcohol: | |
| Use of tobacco: | |
| Use of illicit drugs: | |
| EMOTIONAL HISTORY (15 points) | |
| Mental, emotional or psychiatric problems: | |
| FAMILY HISTORY (20 points) | |
| Father: | |
| Mother: | |
| Siblings: | |
| Grandparents: | |
| PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 points) | |
| Occupational history: | |
| Educational level: | |
| Financial background: | |
| ROLES AND RELATIONSHIPS (15 points) | |
| Significant others: | |
| Support systems: | |
| ETHNICITY AND CULTURE (15 points) | |
| Ethnicity and culture: | |
| Physical and social characteristics that influence healthcare decisions: | |
| SPIRITUALITY (5 points) | |
| Religious and spiritual needs: | |
| SELF-CONCEPT (5 points) | |
| View of self-worth: | |
| Future plans: | |
| REVIEW OF SYSTEMS (25 points) (Please refer to your assignment guidelines and Chapter 4 of your text. This is not a physical examination.) | |
| Skin, hair, nails: | |
| Head, neck, related lymphatics: | |
| Eyes: | |
| Ears, nose, mouth, and throat: | |
| Respiratory: | |
| Breasts and axillae: | |
| Cardiovascular: | |
| Peripheral vascular: | |
| Abdomen: | |
| Urinary: | |
| Reproductive: | |
| Musculoskeletal: | |
| Neurologic: |