Classroom Assignment Week Two

Date __________________________ Examiner ______________________

1. Biographic Data Name _______________________________________________ Phone________________________ Address____________________________________________________________________________ Birthdate ________________________________ Birthplace _________________________________ Age __________ Gender __________ Marital Status ______________ Occupation _______________ Race/ethnic origin __________________________________ Employer ________________________


. Source and Reliability

3. Reason for Seeking Care

Present Health or History of Present Illness

Past Health History

Describe general health ______________________________________________________________ Childhood illnesses __________________________________________________________________ Accidents or injuries (include age) ______________________________________________________ Serious or chronic illnesses (include age) ________________________________________________ Hospitalizations (what for? location?) ____________________________________________________ Operations (name procedure, age) ______________________________________________________
Obstetric history: Gravida ____________ Term ____________ Preterm ____________ (# Pregnancies)
(# Term pregnancies) (# Preterm pregnancies)
Ab/incomplete _____________________ Children living _____________________ (# Abortions or miscarriages) _____

Course of pregnancy__________________________________________________________________ (Date delivery, length of pregnancy, length of labor, baby’s weight and sex, vaginal delivery or cesarean section, complications, baby’s condition)

Last examination date: Physical ________________

Dental ________________ Vision ________________
Allergies _________________________________ Reaction __________________________________

Current medications _________________________________________________________________ _

6. Family History—Specify Which Relative(s)

Heart disease___________________________ High blood pressure______________________ Stroke_________________________________ Diabetes_______________________________

Blood disorders_________________________ Breast or ovarian cancer___________________

Cancer (other)__________________________ Sickle cell______________________________ Arthritis_______________________________
Allergies_______________________________ Asthma _______________________________ Obesity________________________________ Alcoholism or drug addiction ______________

Mental illness ___________________________ Suicide ________________________________

Seizure disorder ________________________ Kidney disease __________________________ Tuberculosis _____

Review of Systems (Circle/highlight both past health problems that have been resolved and current problems, including date of onset.)

General Overall Health State: Present weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats or night sweats

Skin: History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion

Hair: Recent loss, change in texture

Nails: Change in shape, color, or brittleness

Health Promotion: Amount of sun exposure, method of self-care for skin and hair

Head: Any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigo

Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts

Health Promotion Eyes: Wears glasses or contacts, last vision check or glaucoma test, how coping with loss of vision, if any

Ears: Earaches, infections, discharge and its characteristics, tinnitus, or vertigo

Health Promotion Ears: Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning ears

Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell

Mouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste

Health Promotion/Mouth & Throat: Pattern of daily dental care, use of prostheses (dentures, bridge), and last dental checkup

Neck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter

Breast: Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts Axilla: Tenderness, lump or swelling, rash

Health Promotion Breast: Performs breast self-examination, including frequency and method used, last mammogram and results

Respiratory System: History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure
Health Promotion Respiratory: Last chest x-ray examination

Cardiovascular System: Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion it takes to produce dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia

Health Promotion Cardiovascular: Date of last ECG or other heart tests and results

Peripheral Vascular System: Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers
Health Promotion Peripheral Vascular: If work involves long-term sitting or standing, avoid crossing legs at the knees; wear support hose.

Gastrointestinal System: Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula)

Health Promotion Gastrointestinal: Use of antacids or laxatives

Urinary System: Frequency, urgency, nocturia (the number of times awakens at night to urinate, recent change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or low back

Health Promotion Urinary: Measures to avoid or treat urinary tract infections, use of Kegel exercises

Male Genital System: Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia

Health Promotion Male Genital: Perform testicular self-examination? How frequently?

Female Genital System: Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding.

Health Promotion Female Genital: Last gynecologic checkup, last Pap test and results

Sexual Health: Presently in a relationship involving intercourse? Are aspects of sex satisfactory to you and partner, any dyspareunia (for female), any changes in erection or ejaculation (for male), use of contraceptive, is contraceptive method satisfactory? Use of condoms, how frequently? Aware of any contact with partner who has sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, syphilis)?

Musculoskeletal System: History of arthritis or gout. In the joints: pain, stiff-ness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gait prob-lems or problems with coordinated activities. In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease.

Health Promotion Musculoskeletal: How much walking per day? What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? Any mobility aids used?

Neurologic System: History of seizure disorder, stroke, fainting, blackouts. In motor function: weakness, tic or tremor, paralysis, coordination problems. In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent or distant, disorientation). In mental status: any nervousness, mood change, depression, or any history of mental health dysfunction or hallucinations.

Hematologic System: Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.

Endocrine System: History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat or cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy.

Functional Assessment (Including Activities of Daily Living)

Self-Esteem, Self-Concept: Education (last grade completed, other significant training) ______________

Financial status (income adequate for lifestyle and/or health concerns) __________

Value-belief system (religious practices and perception of personal strengths) ___________

Self-care behaviors ______________________

Activity and Exercise: Daily profile, usual pattern of a typical day ________________________________

Independent or needs assistance with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, climbing stairs _________________________________

Leisure activities ________________________________________

Exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring

Sleep and Rest: Sleep patterns, daytime naps, any sleep aids used ___________________

Nutrition and Elimination: Record 24-hour diet recall. _______________________________________ _____________________________________________________________________________________

Is this menu pattern typical of most days? ___________________________________________________

Who buys food? ____________________________

Who prepares food? __________________________

Finances adequate for food? __________________________________

Who is present at mealtimes? __________________________________

Interpersonal Relationships and Resources: Describe own role in family _________________________

How getting along with family, friends, co-workers, classmates ______________________

Get support with a problem from? ______________________________________________

How much daily time spent alone? _______________________________________________________
Is this pleasurable or isolating? ___________________________________________________________

Coping and Stress Management: Describe stresses in life now __________________________________ _____________________________________________________________________________________
Change(s) in past year ______________________________________________

Methods used to relieve stress _______________________

Are these methods helpful? ___________________________

Personal Habits:

Daily intake caffeine (coffee, tea, colas) ______________________________________

Smoke cigarettes? ____________________________
Number packs per day ______________

Daily use for how many years __________________
Age started ___________

Ever tried to quit? ____________________________
How did it go? _____________________________

Drink alcohol? ____________________ Date of last alcohol use _______

Amount of alcohol
that episode __________________________________________________________

Out of last 30 days, on how many days had alcohol? ____________________________________

Ever told had a drinking problem? ________________________________________________________
Any use of street drugs? ___________
Marijuana? _________________________________

Cocaine? __________________________________
Crack cocaine? ______________________________
Amphetamines? _____________________________
Heroin? __________________

Prescription painkillers? _____________________
Barbiturates? _______________________________
LSD? _____________________________________

Ever been in treatment for drugs or alcohol? ________________________________________________

Environment and Hazards: Housing and neighborhood (type of structure, live alone, know neighbors) _____________________________________________________________________________________

Safety of area _________________________________________________________________________
Adequate heat and utilities ____________________________________________________________

Access to transportation ____________________________________________________________

Involvement in community services _______________________________________________________
Hazards at workplace or home ___________________________________________________________
Use of seatbelts ____________________________________________________________________

Travel to or residence in other countries ___________________________________________________
Military service in other countries ________________________________________________________
Self-care behaviors _____________________________________________________________________
Intimate Partner Violence: How are things at home? Do you feel safe? __________________

Ever been emotionally or physically abused by your partner or someone important to you___-

Ever been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner? _____________________________________________________________________________________
Partner ever force you into having sex? ____________________________________________________
Are you afraid of your partner or ex-partner? ________________________________

Occupational Health:

Please describe your job. ______________________________________________

Work with any health hazards (e.g., asbestos, inhalants, chemicals, repetitive motion)? ___________________________________________________________________________________

Any equipment at work designed to reduce your exposure?

Any work programs designed to monitor your exposure? _________________________________

Any health problems that you think are related to your job? _____________________________

What do you like or dislike about your job? _________________________________________________

Perception of Own Health:

How do you define health? ________________________________________

View of own health now ________________________________________________________________

What are your concerns? ________________________________________________________________

What do you expect will happen to your health in future? _______________________

Your health goals ______________________________________________________________________

Your expectations of nurses, physicians ___________________________________________________