Health history and care plans
Assume you are interviewing a 65 year old African American woman
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.
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: