Advanced Health Assessment
Documentation Form
Date: 04/10/2026
Table 1: Patient Demographics and Vital Signs
Demographic and Results
Vitals
Patient Name Tyquasha
(verbalize in video) Ellerbe
Age 19
Sex assigned at birth Female
Gender identity Female
Preferred pronouns None
Race/ethnicity Black
Marital status Single
Height 62 inches
Weight 127 lbs
Body mass index 23.2
(BMI)
Temperature N/A
Respiratory rate 18
Heart rate 62
Blood pressure 122/74
Chief Complaint
Complete an annual physical, complaint of numbness and tingling in her right hand
and fingers and denies injury/trauma.
History of Present Illness (HPI)/Focused Orthopedic
Patient reports numbness and tingling in the right hand that began approximately 2-
3 weeks ago and has been gradually increasing. Numbness and tingling are focused
on the right thumb, index and middle fingers and radiating intermittently to the wrist
on the radial side. The sensation is described as “pins and needles” and weakness;
she has decreased grip with symptoms only. She states it is worse when she is typing
on her phone, writing, and at night when sleeping on her right side. Patient states
symptoms improve when she shakes, stretches her hand, or rests. Reports rest to
improve symptoms, no medication. She states pain 0/10, when numbness occurs,
interfering with her sleep and her ability to use her hand during the day.
Table 2: Medication Information
Name Dose and Directions Indication
None
Western Governors University 1|Page
Accessibility Review Completed and Approved for Distribution and Use. [AEC0005927]
Academic Product Management [VD - Based on review completed 02/11/25.]
, Table 3: Allergies with Reactions
Allergies Reactions
• No known food or drug allergies •
• •
Table 4: Past Medical History (PMH)
Surgeries or Dates: No prior surgical history
Other Medical
History
Table 5: Vaccinations
Flu Date: Pneumovax Date: Tetanus Date:
Given 10/28/2025 Refused 01/21/2026 Given 11/06/2025
Table 6: Family History (if applicable): Specify any known
diseases or disorders, whether the individual is living or
deceased, and their age at death (if deceased)
Relative Alive or
Disease/Disorder Age at Death
Deceased
Mother None Alive
Father None Alive
Siblings None Alive
MGM None Alive
MGF None Alive
PGM None Alive
PGF None Alive
Personal and Social Hx
Current or former tobacco user:
Never Smoked
Year started:
N/a
Year stopped:
Western Governors University 2|Page
Accessibility Review Completed and Approved for Distribution and Use. [AEC0005927]
Academic Product Management [VD - Based on review completed 02/11/25.]
, N/a
Amount used per day:
N/a
Alcohol consumption:
Never
Substance use:
Never
Exercise habits:
3-5 times weekly, 1 hour
Safety habits (e.g., seatbelt and helmet usage, texting and driving):
Yes, seatbelts are always fastened
Highest level of education:
College
Literacy level and language:
Proficient in English
Occupation:
Student
Financial and insurance concerns:
None currently
Support system (family and friends):
I have 2 children and 1 sister
Transportation method:
Private car
Access to phone and internet:
Yes, access to both phone and internet
Religion and related health needs:
Christian has no related health needs currently
Interest and hobbies (health risks):
Enjoy reading and spending time with friends
Sexual history:
Sexually active with one male partner for the past 3 years. No history of STD/STI.
Patient states she has an IUD for birth control. Denies condom use with partner.
Western Governors University 3|Page
Accessibility Review Completed and Approved for Distribution and Use. [AEC0005927]
Academic Product Management [VD - Based on review completed 02/11/25.]
Documentation Form
Date: 04/10/2026
Table 1: Patient Demographics and Vital Signs
Demographic and Results
Vitals
Patient Name Tyquasha
(verbalize in video) Ellerbe
Age 19
Sex assigned at birth Female
Gender identity Female
Preferred pronouns None
Race/ethnicity Black
Marital status Single
Height 62 inches
Weight 127 lbs
Body mass index 23.2
(BMI)
Temperature N/A
Respiratory rate 18
Heart rate 62
Blood pressure 122/74
Chief Complaint
Complete an annual physical, complaint of numbness and tingling in her right hand
and fingers and denies injury/trauma.
History of Present Illness (HPI)/Focused Orthopedic
Patient reports numbness and tingling in the right hand that began approximately 2-
3 weeks ago and has been gradually increasing. Numbness and tingling are focused
on the right thumb, index and middle fingers and radiating intermittently to the wrist
on the radial side. The sensation is described as “pins and needles” and weakness;
she has decreased grip with symptoms only. She states it is worse when she is typing
on her phone, writing, and at night when sleeping on her right side. Patient states
symptoms improve when she shakes, stretches her hand, or rests. Reports rest to
improve symptoms, no medication. She states pain 0/10, when numbness occurs,
interfering with her sleep and her ability to use her hand during the day.
Table 2: Medication Information
Name Dose and Directions Indication
None
Western Governors University 1|Page
Accessibility Review Completed and Approved for Distribution and Use. [AEC0005927]
Academic Product Management [VD - Based on review completed 02/11/25.]
, Table 3: Allergies with Reactions
Allergies Reactions
• No known food or drug allergies •
• •
Table 4: Past Medical History (PMH)
Surgeries or Dates: No prior surgical history
Other Medical
History
Table 5: Vaccinations
Flu Date: Pneumovax Date: Tetanus Date:
Given 10/28/2025 Refused 01/21/2026 Given 11/06/2025
Table 6: Family History (if applicable): Specify any known
diseases or disorders, whether the individual is living or
deceased, and their age at death (if deceased)
Relative Alive or
Disease/Disorder Age at Death
Deceased
Mother None Alive
Father None Alive
Siblings None Alive
MGM None Alive
MGF None Alive
PGM None Alive
PGF None Alive
Personal and Social Hx
Current or former tobacco user:
Never Smoked
Year started:
N/a
Year stopped:
Western Governors University 2|Page
Accessibility Review Completed and Approved for Distribution and Use. [AEC0005927]
Academic Product Management [VD - Based on review completed 02/11/25.]
, N/a
Amount used per day:
N/a
Alcohol consumption:
Never
Substance use:
Never
Exercise habits:
3-5 times weekly, 1 hour
Safety habits (e.g., seatbelt and helmet usage, texting and driving):
Yes, seatbelts are always fastened
Highest level of education:
College
Literacy level and language:
Proficient in English
Occupation:
Student
Financial and insurance concerns:
None currently
Support system (family and friends):
I have 2 children and 1 sister
Transportation method:
Private car
Access to phone and internet:
Yes, access to both phone and internet
Religion and related health needs:
Christian has no related health needs currently
Interest and hobbies (health risks):
Enjoy reading and spending time with friends
Sexual history:
Sexually active with one male partner for the past 3 years. No history of STD/STI.
Patient states she has an IUD for birth control. Denies condom use with partner.
Western Governors University 3|Page
Accessibility Review Completed and Approved for Distribution and Use. [AEC0005927]
Academic Product Management [VD - Based on review completed 02/11/25.]
