Course Project Milestone #1: Health History Form Your Name: Date: 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: Initials: Age: Date of birth: Birthplace: Gender: Marital status: Race: Religion: Occupation: Health insurance: Source of information: Reliability of source of information: PRESENT HEALTH HISTORY/ILLNESS (15 pts) Reason for seeking care: Health patterns: Health goals: HEALTH BELIEFS AND PRACTICES (15 pts) Beliefs and practices: Factors influencing healthcare decisions: Related traits, habits or acts: MEDICATIONS (15 pts) (Please refer to your assignment guidelines.) Prescription medications: Over-the-counter medications: Herbals: PAST HISTORY (15 pts) Childhood diseases: Immunizations: Allergies: Blood transfusions: Major illnesses: Injuries: Hospitalizations: Labor and deliveries: Surgeries: Use of alcohol: Use of tobacco: Use of illicit drugs: EMOTIONAL HISTORY (15 pts) Mental, emotional or psychiatric problems: FAMILY HISTORY (15 pts) Father: Mother: Siblings: Grandparents: PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts) Occupational history: Educational level: Financial background: ROLES AND RELATIONSHIPS (15 pts) Significant others: Support systems: ETHNICITY AND CULTURE (10 pts) Ethnicity and culture: Physical and social characteristics that influence healthcare decisions: SPIRITUALITY (5 pts) Religious and spiritual needs: SELF-CONCEPT (5 pts) View of self-worth: Future plans: REVIEW OF SYSTEMS (20 pts)(Please refer to your assignment guidelines and chapter 4 of your text. This is NOT a physical assessment.) Skin, hair, nails: Head, neck, related lymphatics: Eyes: Ears, nose, mouth, and throat: Respiratory: Breasts and axillae: Cardiovascular: Peripheral vascular: Abdomen: Urinary: Reproductive: Musculoskeletal: Neurologic: week 6
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