Chamberlain College of Nursing
NR305 Health Assessment
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 Course
Resources to complete the information below. This assignment is worth 200 points, with 10 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, for example, 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.” If the client fails to disclose answers to several items, you will need to find another client who
is willing to share.
Note: Failing to complete this assignment using an adult participant other than yourself will result in a
20% penalty deduction being applied.
BIOGRAPHICAL DATA (10 points)
Date: September 23, 2017
Initials: KP
Age: 24
Date of birth: December 11, 1992
Birthplace: Columbus, OH
Gender: Female
Marital status: Married
Race: Caucasian
Religion: Christian
Occupation: Registered Nurse
Health insurance: Patient states she has insurance through Southern Ohio Medical
Center, which is place of employment
Source of information: Patient
Reliability of source of information: Patient seems reliable, alert and oriented x3
PRESENT HEALTH HISTORY/ILLNESS
(20 points)
Reason for seeking care: “ Knee pain after skiing trip. My knee is throbbing without relief;
I cannot bend my knee or walk. I fell while skiing and I heard a
popping noise, It started hurting immediately and has not
stopped. I can not take care of my house or work with my knee
like this ”
Milestone 1: Health History Form Rev: 4/25/17 als 1
This study source was downloaded by 100000852681095 from CourseHero.com on 01-30-2023 06:05:01 GMT -06:00
https://www.coursehero.com/file/60077836/Carson-P-Milestone-Health-History-Formdocx/
, Chamberlain College of Nursing
NR305 Health Assessment
Health patterns: “ I am healthy right now, my knee just hurts”
Health goals: “ To be able to walk and work without throbbing knee pain”
HEALTH BELIEFS AND PRACTICES (15
points)
Beliefs and practices: Patient states she does not have an specific beliefs or practices
relating to her health care visit
Factors influencing healthcare No factors stated from patient
decisions:
Related traits, habits or acts: Patient states she “goes to church on Sunday”, but has “no other
traits, habits or acts”.
MEDICATIONS (20 points) (Please
refer to your assignment
guidelines.)
Prescription medications: Patient states she is on “ 28 day pack of Orthothrycycline Low “
for birth control and “Lipitor 40mg” for Cholesterol
Over-the-counter medications: Patient states she “takes 200mg of Advil sometimes for
headache, Metamucil x3 a week and a daily fish oil pill to help
with her cholesterol ”
Herbals: Patient states she doesn’t take any herbal medication
PAST HISTORY (20 points)
Childhood diseases: Patient states she had the chicken poxs when she was 3 years
old. Patient denies any additional childhood illnesses
Immunizations: Patient is up to date with immunizations according to the CDC
recommendations. Patient states she “ got a Tdap booster when
she was hired as a RN in 2015”.
Allergies: Patient states “ she has no allergies that she is aware of “
Blood transfusions: Patient denies ever receiving a blood transfusion
Major illnesses: Patient denies any major illnesses
Injuries: Patients states “ my knee is my first injury “
Hospitalizations: Patient denies every being hospitalized
Labor and deliveries: Patient is a Grav 0, denies ever being pregnant
Surgeries: Patient states she has had a cyst removed from her tonsils in
2011 and a “planters wart” removed in 2010. Patient denies any
other surgeries
Use of alcohol: Patient states she occasionally drinks alcohol “maybe 1x a
month”
Use of tobacco: Patient denies any use of tobacco
Use of illicit drugs: Patient denies any use of illicit drugs
EMOTIONAL HISTORY (15 points)
Mental, emotional or psychiatric
problems:
FAMILY HISTORY (20 points)
Father: Patient states her Father has a history of “bilateral hip
replacement and hyperlipidemia”
Mother: Patient states her mother has a history of “ foot fracture, anxiety,
depression, miscarriage and gallbladder removal”
Milestone 1: Health History Form Rev: 4/25/17 als 2
This study source was downloaded by 100000852681095 from CourseHero.com on 01-30-2023 06:05:01 GMT -06:00
https://www.coursehero.com/file/60077836/Carson-P-Milestone-Health-History-Formdocx/
NR305 Health Assessment
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 Course
Resources to complete the information below. This assignment is worth 200 points, with 10 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, for example, 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.” If the client fails to disclose answers to several items, you will need to find another client who
is willing to share.
Note: Failing to complete this assignment using an adult participant other than yourself will result in a
20% penalty deduction being applied.
BIOGRAPHICAL DATA (10 points)
Date: September 23, 2017
Initials: KP
Age: 24
Date of birth: December 11, 1992
Birthplace: Columbus, OH
Gender: Female
Marital status: Married
Race: Caucasian
Religion: Christian
Occupation: Registered Nurse
Health insurance: Patient states she has insurance through Southern Ohio Medical
Center, which is place of employment
Source of information: Patient
Reliability of source of information: Patient seems reliable, alert and oriented x3
PRESENT HEALTH HISTORY/ILLNESS
(20 points)
Reason for seeking care: “ Knee pain after skiing trip. My knee is throbbing without relief;
I cannot bend my knee or walk. I fell while skiing and I heard a
popping noise, It started hurting immediately and has not
stopped. I can not take care of my house or work with my knee
like this ”
Milestone 1: Health History Form Rev: 4/25/17 als 1
This study source was downloaded by 100000852681095 from CourseHero.com on 01-30-2023 06:05:01 GMT -06:00
https://www.coursehero.com/file/60077836/Carson-P-Milestone-Health-History-Formdocx/
, Chamberlain College of Nursing
NR305 Health Assessment
Health patterns: “ I am healthy right now, my knee just hurts”
Health goals: “ To be able to walk and work without throbbing knee pain”
HEALTH BELIEFS AND PRACTICES (15
points)
Beliefs and practices: Patient states she does not have an specific beliefs or practices
relating to her health care visit
Factors influencing healthcare No factors stated from patient
decisions:
Related traits, habits or acts: Patient states she “goes to church on Sunday”, but has “no other
traits, habits or acts”.
MEDICATIONS (20 points) (Please
refer to your assignment
guidelines.)
Prescription medications: Patient states she is on “ 28 day pack of Orthothrycycline Low “
for birth control and “Lipitor 40mg” for Cholesterol
Over-the-counter medications: Patient states she “takes 200mg of Advil sometimes for
headache, Metamucil x3 a week and a daily fish oil pill to help
with her cholesterol ”
Herbals: Patient states she doesn’t take any herbal medication
PAST HISTORY (20 points)
Childhood diseases: Patient states she had the chicken poxs when she was 3 years
old. Patient denies any additional childhood illnesses
Immunizations: Patient is up to date with immunizations according to the CDC
recommendations. Patient states she “ got a Tdap booster when
she was hired as a RN in 2015”.
Allergies: Patient states “ she has no allergies that she is aware of “
Blood transfusions: Patient denies ever receiving a blood transfusion
Major illnesses: Patient denies any major illnesses
Injuries: Patients states “ my knee is my first injury “
Hospitalizations: Patient denies every being hospitalized
Labor and deliveries: Patient is a Grav 0, denies ever being pregnant
Surgeries: Patient states she has had a cyst removed from her tonsils in
2011 and a “planters wart” removed in 2010. Patient denies any
other surgeries
Use of alcohol: Patient states she occasionally drinks alcohol “maybe 1x a
month”
Use of tobacco: Patient denies any use of tobacco
Use of illicit drugs: Patient denies any use of illicit drugs
EMOTIONAL HISTORY (15 points)
Mental, emotional or psychiatric
problems:
FAMILY HISTORY (20 points)
Father: Patient states her Father has a history of “bilateral hip
replacement and hyperlipidemia”
Mother: Patient states her mother has a history of “ foot fracture, anxiety,
depression, miscarriage and gallbladder removal”
Milestone 1: Health History Form Rev: 4/25/17 als 2
This study source was downloaded by 100000852681095 from CourseHero.com on 01-30-2023 06:05:01 GMT -06:00
https://www.coursehero.com/file/60077836/Carson-P-Milestone-Health-History-Formdocx/
