Comprehensive Health Assessment Documentation Form

Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Amanda Owens Date: December 26, 2016 Patient Information Patient Initials J.O. Age 35 Sex Male Chief Complaint Routine Annual Exam History of Present Illness (HPI) 35 year old presents for routine annual exam. No present illness or complaint. 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications None Allergies No known drug allergies Medical HX (PMH) Childhood No significant findings Adult No significant findings Surgical None Ob/Gyn N/A Psychiatric No significant findings Vaccinations Flu Date:10/1/16 Pneumovax Date: None Tetanus Date: 7/15/10 Family HX (specify family member affected/age at death) No significant findings. All family is alive and without medical problems per patient. Social/Environmental HX  HTN  DM  Ca  MI/CAD  CVA  TB N/A  Renal dz  Thyroid dz  Suicide  Alcoholism  Substance abuse N/A Born in: Las Vegas Education: Associate Degree Occupation: Police Officer Family situation: Married w/2 kids Transportation options: Drive SUV Insurance: Double insured Neighborhood: Upscale Urban neighborhood Language/Literacy: English Access to emerging technologies: Cell phone, computer, internet access, ability to afford technology Interests/Hobbies: Outdoor activities, hunting, working out   …………………………………CONTINUED……………………………………..