All documents need to be submitted in doc or docx format.
Health History and Narrative summary need to be one document.
Genogram can be submitted as separate document.
PLEASE NOTE : This is part one of two and care plans would be done in a later assignment. Keep that in mind.
Biographical Data
Date/Time:
Initials:
Address:
Source of Information: DOB:
Age:
Gender:
Race:
Marital Status:
Ethnic Identity/Culture:
Religion:
Occupation:
Health Insurance (Type/Coverage):
LIVING ARRANGEMENTS:
Number in household:
Designated Caregiver: Home Conditions:
?Clean ? Unclean Safety:
?Good ?Fair ?Poor Hygiene:
?Good ?Fair ?Poor
Comments: (Identify potential risks)
Present Health or Illness:
VITAL SIGNS:
TEMP:
Source:
PULSE:
Source: BP
Site: Respiration
Rhythm: Pain Score Height (ft/in) Weight (lbs)(kgs)
Health Beliefs and Practices, health patterns
Medications: (Be sure to include OTC and Herbals, in addition to prescription medications)
Current Medications Name: Dose Schedule Prescribing Physician
ACTIVITIES OF DAILY LIVING:
ACTIVITY INDEPENDENT NEEDS ASSISTANCE DEPENDENT RECOMMENDATIONS/COMMENTS
Feeding
Ambulating
Transfer Bed
Transfer Toilet
Transfer Tub
Grooming
Oral hygiene
Dressing
Bathing
Food preparation
Shopping
Medications
Finances
Access ER services
Past Medical History (PMH)
CHRONIC CONDITIONS: (Year diagnosed, treatment, status, managing PCP)
ALLERGIES:
Medications:
Foods:
Environmental:
Other:
COMMENTS:
IMMUNIZATIONS:
• Are childhood/adolescent up to date: Yes No
• Immunizations in past year:
• Adverse Reaction to immunization: Yes No
• If yes describe:
Surgical History: Year, Procedure, (Physician and Institution, if known)
SEXUAL HISTORY
Any concerns:
For females: Age at Onset of Menses/Menarche
Family History:
• Immediate Family
• Extended family
• Complete your family history utilizing the following link and create a Genogram for your client. https://familyhistory.hhs.gov/fhh-web/home.action
For optimal assignment credit, please take a screen shot or copy and submit electronically as a separate attachment with this assignment.
Psychosocial History
• Occupation History
• Education
• Financial Background
• Roles and Relationships
• Family
• Social Structure/Emotional Concerns
• Self-Concept
• Spirituality
Review of Body Systems (ROS)
This is an interview about current or significant past medical issues/concerns (Head to Toe) that may impact planning of care.
• Skin, Hair, and Nails
• Head Neck and Lymphatic
• Eyes
• Ears, nose, Mouth, and Throat
• Respiratory
• Breast and Axillae
• Cardiovascular
• Peripheral Vascular
• Abdomen
• Urinary
• Male/Female Reproductive
• Musculoskeletal
• Neurologic
List any Safety Concerns:
Nursing Narrative Note:
Health history and care plans
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