Course Project Milestone #1: Health History Form
Your Name: Date: 6/2/13
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_Milestone#1_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: | 5/25/13 |
Initials: | C.G. |
Age: | 55 |
Date of birth: | 8/12/58 |
Birthplace: | Grenada |
Gender: | Male |
Marital status: | Married |
Race: | Caribbean African |
Religion: | Christianity |
Occupation: | Auto-Mechanic |
Health insurance: | Aetna |
Source of information: | Client |
Reliability of source of information: | Client is alert and oriented x3, responsive, ability to recall and process information intact. |
PRESENT HEALTH HISTORY/ILLNESS (15 pts) | |
Reason for seeking care: | Routine physical checkup. Have complaints about indigestion, acid reflux, difficulty falling asleep and feeling tired in the mornings. |
Health patterns: | Avoids seeing the doctor for “minor things.” States “Growing up as a child in...