NURSING MS C350 Comprehensive Health Assessment Documentation Form/ Patient Initials A.H.

Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:9/29/2019 Patient Information Patient Initials A.H. Age 37 Sex Female Chief Complaint No complaints of illness History of Present Illness (HPI) Uterine Fibroid Tumors since 2018 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Vitamin C- 500mg daily Vitamin D- 1000 I U DAILY L-Lysine 1000mg Allergies Morphine Benadryl Medical HX (PMH) Childhood No childhood disease Adult Negative Surgical Negative Ob/Gyn Uterine Fibroid Tumors Psychiatric Negative Vaccinations Flu Date:10/18 Pneumovax Date: refuse Tetanus Date: up-to -date Family HX (specify family member affected/age at death) Mother has hypertension Father has Diabetes Type 2 Maternal Grandmother unknown Paternal Grandfather unknown Social/Environmental HX ⦁ HTN- na ⦁ DM-na ⦁ Ca-na ⦁ MI/CAD-na ⦁ CVA- na ⦁ TB- na ⦁ Renal dz na ⦁ Thyroid dz- na ⦁ Suicide- na ⦁ Alcoholism-na ⦁ Substance abuse-na Born in: Detroit, Michigan Education: High school Graduate/ 2 years of college Occupation: Nurse Family situation: Single/ no children Transportation options: Reliable Car Insurance:Blue Cross Blue Shield Neighborhood: safe/ Suburban area Language/Literacy: English Access to emerging technologies: Iphone, Macbook Interests/Hobbies: painting, creating jewelry, drawing, exercise, movie goer