The purpose of this assignment is to provide the student an opportunity to pract

The purpose of this assignment is to provide the student an opportunity to practice performing a writing comprehensive health history on a client. The health history provides a complete picture of a client’s past and present health. The student will be able to use this health history as a screening tool for abnormal symptoms, health problems, and concerns; and it records ways of responding to the health problems. The health history is typically done on admission to the hospital and may be taken when additional subjective information is crucial to inform the healthcare providers.
Guidelines
Interview Preparation
Ø Find a family member or friend with a stable medical condition and complete your health history assignment.
Ø Use only initials for identification. The adult age must be 21 and up.
Write-Up
Ø The paper must be written using Times New Roman 12 using the health history form.
Ø It is required to utilize the rubric to achieve maximum points.
Ø Minimum of two references (the course textbook can be one of the references). Scholarly articles chosen must have been published within the last 5 years. Articles chosen must have been published within the last 5 years.
Course Student Learning Outcome Address (CSLOs)
1. Correlate varying assessment findings with culture, age, and gender
End of Program Student Learning Outcomes Address (EOPSLOs)
9. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches
Health History
Type of Data
Client’s Information
Biographic Data
Name
Address
Telephone numbers
Age
Birth date
Birthplace
Gender
Marital status
Race
Cultural background or ethnic origin
Spiritual or religious preference
Educational level
Occupation
Source and Reliability
Patient, who seems reliable
Reason for Seeking Care
Statement of the client’s own words that describes the reason for the visit
Present Health or History of Present Illness
Statement about the general state of health
Allergies
Medication
Food (e.g., peanuts, eggs)
Environmental agents (e.g., latex, tape, detergents)
Reaction to reported allergens (e.g., rash, breathing difficulty, nausea, vomiting)
Contrast dye
Medication Reconciliation
Prescription
Over-the-counter medications and herbal remedies
Dosage, frequency, and reason for use
Immunizations
Childhood and adult immunizations
Date of last tuberculin skin test
Date of last vaccines (e.g., flu, pneumonia, shingles)
Medical history
Childhood illnesses, accidents, and injuries
Serious or chronic illnesses
Hospitalizations, including obstetric history for female patients
Date of occurrence and current treatment
Obstetric history
Last examination date
Surgical history
Type of surgery
Date
Problems with anesthesia
Any complications
Family history
Age and health status of living parents, grandparents, siblings, and children
Age at death and cause of death of deceased immediate family members
Genetic diseases or traits, familial diseases (e.g., cardiovascular disease, high blood pressure, stroke, blood disorders, cancer, diabetes, kidney disease, seizure disorders, drug or alcohol dependencies, mental illness)
Create a genogram.
Social history
Use of tobacco, alcohol, or recreational drugs
Environmental exposures
Animal exposures and pets
Living arrangement
Safety concerns (e.g., intimate-partner violence, emotional or physical abuse)
Recent domestic or foreign travel
Cultural, spiritual, and religious tradition
Primary language
Dietary restrictions
Religion
Values and beliefs related to health care
Activities of daily living (ADL’s)
Nutrition (e.g., meal preparation, shopping, typical 24-hour dietary intake); recent changes in appetite
Caffeine intake
Self-care activities (e.g., bathing, dressing, grooming, ambulation)
Physical living environment (e.g., steps, access to toileting or sleeping areas, indoor plumbing, carpet or rugs)
Use of prosthetics or mobility devices
Leisure and exercise activities
Sleep patterns (e.g., hours per night, naps, sleep aids)
Cognitive or emotional status
Cognitive functioning
Personal strengths
Self-esteem
Support system (e.g., family, friend, support groups, professional counseling)
Review of systems
General overall health of state
Health promotion (for all the systems)
Skin, hair, and nails
Head
Eyes
Ears
Nose and sinuses
Mouth and throat
Neck
Breast and axilla
Respiratory system
Cardiovascular system
Peripheral vascular
Gastrointestinal
Urinary system
Male/female genital system
Sexual health
Musculoskeletal system
Neurological system
Hematology system
Endocrine system