NURSING MS C-350 Comprehensive Health Assessment Documentation Form/ Patient Initials JH

Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:_________ Patient Information Patient Initials JH Age 41 Sex Male Chief Complaint Initial assessment to establish care History of Present Illness (HPI) No current complaints 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Lamictal 200mg PO daily Mood Stabilization Ambien 10mg po qHS Insomnia Albuterol inhaler 90mcg/act 1-2 puffs q 4h PRN wheezing Allergies oysters Medical HX (PMH) Childhood Had chicken pox; fully vaccinated; No other notable illnesses/injuries Adult No notable injuries or illnesses Surgical Had a non-malignant polyp removed from head ~ age 2 years Ob/Gyn 1 son 5yo Psychiatric Mood instability; no official diagnosis; managed by PCP Vaccinations Flu Date: 2018 Pneumovax Date: NA Tetanus Date: ~15 years ago Family HX (specify family member affected/age at death) Father: Type II diabetes, mental illness Maternal Grandfather: prostate cancer Paternal Grandfather: multiple MIs; deceased in early 1990s Paternal Grandmother: emphysema