Your Name: Paola Sanchez Date: 11/22/2013
Your Instructor’s Name:
Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 175 points, with 5 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language.
Type your answers on this form. Click “Save as” and save the file with the assignment name and your last name, e.g., “NR305_Milestone1_Form_Smith” When you are finished, submit the form to the Milestone #1 Dropbox by the deadline indicated in your guidelines. Post questions in the Q&A Forum or contact your instructor if you have questions about this assignment.
Disclaimer: The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.”
BIOGRAPHICAL DATA (10 pts)
Date of birth:
San Lorenzo, Puerto Rico
Medicare Part A and B / Supplemental AARP
Source of information:
Primary Source- Client
Reliability of source of information:
Very reliable. Client is able to provide clear and accurate information regarding health history.
PRESENT HEALTH HISTORY/ILLNESS (15 pts)
Reason for seeking care:
Severe headache for the past three days and elevated blood pressure.
Sleeps around 6-7 hours a night. Wakes up about 3 times during the night to urinate. Client is up to date with physical and has had yearly mammogram. Client had colonoscopy