Comprehensive Health Assessment

Topics: Human skin color, Pain / Pages: 24 (5994 words) / Published: Mar 27th, 2012
COMPREHENSIVE WRITTEN ASSESSMENT

Complete Nursing Health History
Biographical Data
Name: B.R.
Address: xxxxxxx
Phone: xxxxx
Gender: Female
Provider of History: Client
Birth Date: February 2, 1973
Place of Birth: Portland, Oregon
Race: Caucasian
Educational Level: Associate’s Degree in Nursing and currently pursuing Bachelor’s of Science in Nursing
Occupation: Registered Nurse
Significant Other: Fiancé “Mark”
Support Person(s): Mother & Brother
Reason for Seeking Healthcare Client is currently seeking healthcare for her yearly routine physical. Client’s last check-up with her primary physician was one year ago, at which time, no abnormal findings were noted. Client is confident with her health at this time and she believes in being pro-active with her health and obtains a routine physical yearly for wellness and prevention.
History of Present Health Concern Client denies any concerns or health complaints. At this time, client is requesting a routine wellness check.
Past Health History
Client denies any problems at birth. Client was adopted at three months old. Client had varicella as a child and currently is up to date on her immunizations. Client receives flu, tetanus, and pneumococcal immunizations at her workplace. Client admits to Adult Attention Deficit Disorder. Following a motor vehicle crash in 2005, client sustained a fractured tibia and fibula. Client subsequently had four tib/fib repair procedures. Client does report chronic back pain remedied by routine chiropractic care. Client is allergic to Sulfa and denies seasonal or environmental allergies.
Family History
See Genogram for this client in Appendix A
Review of Systems for Current Health Problems
Skin, Hair, Nails: Normal skin color for race. Skin warm, dry, intact, no rashes, no lesions. No hair loss or dandruff.
Head and Neck: Denies headache, stiffness, difficulty swallowing, enlarged lymph nodes. No pain.
Ears: Denies pain, ringing, buzzing,

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