RUA Reflection of The Health
History Name…………………..
Chamberlain College of
Nursing NR302: Health
Assessment I January
2020/2021
pg. 1
, HEALTH HISTORY ASSESSMENT 2
Data
Collection
Date:
01/07/2020
Birth date
Client Initials: M. C. Gender: Female and Month:
01/25
Marital status: Single
Date of last
physical exam:
Race: Caucasian Patient States her
“last physical was
in March of 2019.”
Primary Language: English
Source of
Occupation: Practice Manager of an
Information:
Urgent Care
Patient
REASON FOR SEEKING CARE
Patient has come to Chamberlain Hospital seeking care for “consistent diarrhea.”
PRESENT HEALTH/HISTORY OF PRESENT ILLNESS
PALLIATIVE/PROVOCATIVE: Patient states “nothing helps my upset stomach.”
Patient states “my stomach is more upset after eating.”
QUALITY:
Patient states “there is a constant
dull pain in my lower stomach and
my stool is sometimes green not
brown.”
REGION/RADIATING:
Patient states her pain “is in the
lower left side of her stomach
and her middle back area.”
SEVERITY:
pg. 2
History Name…………………..
Chamberlain College of
Nursing NR302: Health
Assessment I January
2020/2021
pg. 1
, HEALTH HISTORY ASSESSMENT 2
Data
Collection
Date:
01/07/2020
Birth date
Client Initials: M. C. Gender: Female and Month:
01/25
Marital status: Single
Date of last
physical exam:
Race: Caucasian Patient States her
“last physical was
in March of 2019.”
Primary Language: English
Source of
Occupation: Practice Manager of an
Information:
Urgent Care
Patient
REASON FOR SEEKING CARE
Patient has come to Chamberlain Hospital seeking care for “consistent diarrhea.”
PRESENT HEALTH/HISTORY OF PRESENT ILLNESS
PALLIATIVE/PROVOCATIVE: Patient states “nothing helps my upset stomach.”
Patient states “my stomach is more upset after eating.”
QUALITY:
Patient states “there is a constant
dull pain in my lower stomach and
my stool is sometimes green not
brown.”
REGION/RADIATING:
Patient states her pain “is in the
lower left side of her stomach
and her middle back area.”
SEVERITY:
pg. 2
