NR 305 Week 4 Course Project Milestone # 1: Health History Form
Your Name: Felipe Teves Jr Date: 3/25/2017
Your Instructor’s Name: Katheryn Csonka
Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Course
Resources to complete the information below. This assignment is worth 200 points, with 10 points
awarded for clarity of writing, which means the use of proper grammar, spelling, and medical language.
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 to the
Milestone #1 Dropbox by the deadline indicated in your guidelines. 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: Failing to complete this assignment using an adult participant other than yourself will result in a
20% penalty deduction being applied.
BIOGRAPHICAL DATA (10 points)
Date: March 22, 2017
Initials: MAS
Age: 39
Date of birth: December 7, 1977
Birthplace: Indiana
Gender: Male
Marital status: Married
Race: Caucasian
Religion: Christian
Occupation: Engineer
Health insurance: Blue Cross Blue Shield
Source of information: Patient himself
Reliability of source of information: Very reliable
PRESENT HEALTH HISTORY/ILLNESS
(20 points)
Reason for seeking care: Neck and Lower Back Pain
Health patterns: Started after Motor Vehicular Accident on December 9, 2016
Health goals: Pain Free
HEALTH BELIEFS AND PRACTICES
(15 points)
Beliefs and practices: Believes in preventive healthcare like annual physical.
Milestone 1: Health History Form Rev. 11/3/16 als 1
Your Name: Felipe Teves Jr Date: 3/25/2017
Your Instructor’s Name: Katheryn Csonka
Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Course
Resources to complete the information below. This assignment is worth 200 points, with 10 points
awarded for clarity of writing, which means the use of proper grammar, spelling, and medical language.
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 to the
Milestone #1 Dropbox by the deadline indicated in your guidelines. 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: Failing to complete this assignment using an adult participant other than yourself will result in a
20% penalty deduction being applied.
BIOGRAPHICAL DATA (10 points)
Date: March 22, 2017
Initials: MAS
Age: 39
Date of birth: December 7, 1977
Birthplace: Indiana
Gender: Male
Marital status: Married
Race: Caucasian
Religion: Christian
Occupation: Engineer
Health insurance: Blue Cross Blue Shield
Source of information: Patient himself
Reliability of source of information: Very reliable
PRESENT HEALTH HISTORY/ILLNESS
(20 points)
Reason for seeking care: Neck and Lower Back Pain
Health patterns: Started after Motor Vehicular Accident on December 9, 2016
Health goals: Pain Free
HEALTH BELIEFS AND PRACTICES
(15 points)
Beliefs and practices: Believes in preventive healthcare like annual physical.
Milestone 1: Health History Form Rev. 11/3/16 als 1
