NR 305_Week 4_Project Course Milestone 1

Course Project Milestone #1: Health History Form

NR 305_Week 4_Project Course Milestone 1

For Use September 18

Your Name: Date: 

Your Instructor’s Name:   

NR 305_Week 4_Project Course Milestone 1

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.

NR 305_Week 4_Project Course Milestone 1

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:9/30/18
Initials:JD
Age:56
Date of birth:3/12/1962
Birthplace:Greenville, NC
Gender:M
Marital status:Widowed
Race:Black
Religion:Baptist
Occupation:MTA bus driver
Health insurance:GHI
Source of information:Person
Reliability of source of information:He is very receptive to questioning and exam
PRESENT HEALTH HISTORY/ILLNESS (20 points)HTN and high cholesterol 
Reason for seeking care:Headaches
Health patterns:Tries to exercise and lower salt intake
Health goals:To lose weight and lower cholesterol and blood pressure.Trying to reduce meat intake and incorporate more vegetables and fruit
HEALTH BELIEFS AND PRACTICES (15 points)
Beliefs and practices:Not really a religious person.  Went to church with parents when he was younger.  Only goes to church during family functions.  Not really a spiritual person but does believe in God and a higher being. 
Factors influencing healthcare decisions:Only reason he found out he had high blood pressure and high cholesterol was from a mandatory annual employee health exam.  He only visits the doctors when he feels sick and he states “He rarely feels sick, so he doesn’t go to the doctors office unless its for his annual physical.
Related traits, habits or acts:Smokes cigarettes – 1 pack dailyDrinks 2-3 beers a day, alcohol socially 
MEDICATIONS (20 points) (Please refer to your assignment guidelines.)
Prescription medications:Ramipril, Lipitor, Baby aspirin
Over-the-counter medications:None
Herbals:none
PAST HISTORY (20 points)
Childhood diseases:Chicken pox
Immunizations:MMR, 
Allergies:Seasonal, No known food or medication allergies
Blood transfusions:none
Major illnesses:
Injuries:none
Hospitalizations:Hospitalized for uncontrolled blood pressure, Went into the hospital for bad headache that would not go away
Labor and deliveries:n/a
Surgeries:None
Use of alcohol:2-3 beers a day, Alcohol socially 
Use of tobacco:1 pack a day since the age of 14
Use of illicit drugs:Smokes weed occasionally 
EMOTIONAL HISTORY (15 points)
Mental, emotional or psychiatric problems:Stated he never been to a psychiatrist, Only has anxiety about “paying bills and retirement” States he is generally happy.  He loves his job and family and relationship”. 
FAMILY HISTORY (20 points)
Father:Died in care accident at the age of 31
Mother:Mother is 71 years old, lives on her own, medical history includes high blood pressure, high cholesterol, and DM type 2.
Siblings:1 brother 42- high blood pressure.  Sister 40 years old with no health issues.
Grandparents:Deceased.  Both grandparents on mother side had DM II and high blood pressure.  Both died of natural causes in their 70’s.Grandparents on father side deceased. Health status unknown.
PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 points)
Occupational history:MTA bus driver
Educational level:High school
Financial background:NYC benefits, Has a 401K and will get full city benefits when he retires after 25 years of employment.
ROLES AND RELATIONSHIPS (15 points)
Significant others:Wife is heathy. married for 17 years.  Together for 25 years.
Support systems:Wife, 3 kids, brother, sister, and their spouses.
ETHNICITY AND CULTURE (15 points)
Ethnicity and culture:Black, African American
Physical and social characteristics that influence healthcare decisions:He began seeing his doctor yearly because its mandated by his employer. Before then he would only go when he felt Ill.
SPIRITUALITY (5 points)
Religious and spiritual needs:He states he is not a spiritual person but believes in god and a higher being, Prays in times of crises.
SELF-CONCEPT (5 points)
View of self-worth:He is proud of his job as it supports him and help pay for kids college.
Future plans:Would like to retire at 66 and travel with his wife.  He is 47 years old and works a lot of overtime to save up for his retirement.  He would like to buy a house down south so his grandkids can come visit and get out of the city,
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:Skin is clear and intact, hair is clean shaven with hair loss in the middle, nails are hard and neatly manicured.  Wife files them for hm.
Head, neck, related lymphatics:No swelling of lymph nodes.  Able to move neck, head with no issues. No pain nor tenderness.
Eyes:Wears glasses to drive and read.  No eye pain. No eye disease.
Ears, nose, mouth, and throat:No pain. no discharge. No irritation.  Has all his teeth.
Respiratory:No respiratory distress172/71 P.89   RR 18 Spo2 97%
Breasts and axillae:n/a
Cardiovascular:No chest pain. No edema.  Hypertension. No trouble breathing. No respiratory distress.
Peripheral vascular:No coldness, numbness, tingling in extremities.  No discoloration.
Abdomen:No abdomen distention. No pain nor tenderness.  
Urinary:Urinary frequency when sitting for to long, but he is able to complete his tour with only using bathroom during break time.
Reproductive:Unknown. Does not want any more children.
Musculoskeletal:No arthritis or gout. No joint pain or swelling.  Mild back discomfort.  Stands up and stretches during breaks which helps.
Neurologic:No neurological disorders.

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