WGU D117/ Advanced Health
Assessment Documentation Form
/Latest Updated
Advanced Health Assessment Documentation
Form
Patient Demographics and Vital Signs
Patient initials MB Height 5’5”
Age 28 Weight 190 lb
Sex assigned at birth Male Body mass index (BMI) 31.62
Gender identity Male Temperature N/a
Preferred pronouns He/him Respiratory rate 16
Race/ethnicity White/Non Heart rate 82
hispanic
Marital status Married Blood pressure 128/78
Chief Complaint
Annual wellness visit and complaints of joint pain in right knee
History of Present Illness (HPI)/Focused Orthopedic
Patient presents to clinic for annual wellness visit as well as complaints of right
knee pain. Patient is being seen for preoperative clearance for knee replacement
surgery. Pt appears well nourished and is A&Ox4. Pt shows no signs or symptoms
of distress. Breathing is normal, and unlabored. Patient has no obvious deformities
and skin color is appropriate for ethnicity. Patient has a history of anxiety,
depression, ADHD, hypertension, and GERD for which he is currently on
medications for. Patient is married and has one three month old son. Pt presents
with a complaint of right sided knee pain that has been going on for about a
month. Patient states the pain is sharp, shooting. Pt reports that nothing seems to
aggravate or alleviate the pain. However, the pain does seem to get worse with
normal movements. Patient reports taking ibuprofen for pain occasionally which
seems to help some. Patient reports at the worst, pain is a 8/10.
1
, Medications
Name Dose and Directions Indication
Vyvanse 70mg once daily Attention Deficit
Hyperactivity Disorder
40mg once daily GERD
Ompeprazole
Valsartan 80mg once daily Hypertension
Wellbutrin 150mg once daily Depression
Zoloft 50mg once daily Anxiety
Motrin 200mg PRN Knee pain
Allergies With Reactions
NKDA
Past Medical History (PMH)
Surgeries and N/A
dates
Other (if
applicable)
Hypertension, GERD, Anxiety/Depression, ADHD
Vaccinations
Flu Date: Pneumovax Date: N/A Tetanus Date:
11/3/2023 11/3/2023
Family History (hx) (specify any disease, if applicable, and if alive or age at
death)
Mother Alive, hypertension
Father Alive, h/o testicular cancer
Siblings Two sisters, one brother, all alive, no reported health issues
MGM Deceased, unsure of health hx (all passed before patient was born)
MGF Deceased, unsure of health hx
PGM Deceased, unsure of health hx
2
Assessment Documentation Form
/Latest Updated
Advanced Health Assessment Documentation
Form
Patient Demographics and Vital Signs
Patient initials MB Height 5’5”
Age 28 Weight 190 lb
Sex assigned at birth Male Body mass index (BMI) 31.62
Gender identity Male Temperature N/a
Preferred pronouns He/him Respiratory rate 16
Race/ethnicity White/Non Heart rate 82
hispanic
Marital status Married Blood pressure 128/78
Chief Complaint
Annual wellness visit and complaints of joint pain in right knee
History of Present Illness (HPI)/Focused Orthopedic
Patient presents to clinic for annual wellness visit as well as complaints of right
knee pain. Patient is being seen for preoperative clearance for knee replacement
surgery. Pt appears well nourished and is A&Ox4. Pt shows no signs or symptoms
of distress. Breathing is normal, and unlabored. Patient has no obvious deformities
and skin color is appropriate for ethnicity. Patient has a history of anxiety,
depression, ADHD, hypertension, and GERD for which he is currently on
medications for. Patient is married and has one three month old son. Pt presents
with a complaint of right sided knee pain that has been going on for about a
month. Patient states the pain is sharp, shooting. Pt reports that nothing seems to
aggravate or alleviate the pain. However, the pain does seem to get worse with
normal movements. Patient reports taking ibuprofen for pain occasionally which
seems to help some. Patient reports at the worst, pain is a 8/10.
1
, Medications
Name Dose and Directions Indication
Vyvanse 70mg once daily Attention Deficit
Hyperactivity Disorder
40mg once daily GERD
Ompeprazole
Valsartan 80mg once daily Hypertension
Wellbutrin 150mg once daily Depression
Zoloft 50mg once daily Anxiety
Motrin 200mg PRN Knee pain
Allergies With Reactions
NKDA
Past Medical History (PMH)
Surgeries and N/A
dates
Other (if
applicable)
Hypertension, GERD, Anxiety/Depression, ADHD
Vaccinations
Flu Date: Pneumovax Date: N/A Tetanus Date:
11/3/2023 11/3/2023
Family History (hx) (specify any disease, if applicable, and if alive or age at
death)
Mother Alive, hypertension
Father Alive, h/o testicular cancer
Siblings Two sisters, one brother, all alive, no reported health issues
MGM Deceased, unsure of health hx (all passed before patient was born)
MGF Deceased, unsure of health hx
PGM Deceased, unsure of health hx
2
