NR305 Milestone1 Form 8 6 13
Course Project Milestone 1: Health History Form
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:
11/22/2013
Initials:
M.S.
Age:
66
Date of birth:
04/16/1947
Birthplace:
San Lorenzo, Puerto Rico
Gender:
Female
Marital status:
Married
Race:
Latino
Religion:
Catholic
Occupation:
Secretary
Health insurance:
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.
Health patterns:
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
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:
11/22/2013
Initials:
M.S.
Age:
66
Date of birth:
04/16/1947
Birthplace:
San Lorenzo, Puerto Rico
Gender:
Female
Marital status:
Married
Race:
Latino
Religion:
Catholic
Occupation:
Secretary
Health insurance:
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.
Health patterns:
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