Posted: April 6th, 2017

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.

Course Project Milestone #1: Health History Form

Your Name: Gina Elie                                                                     Date: 03/18/17

Your Instructor’s Name: Jennifer Marcoaldi

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.

Date of birth:April 10,1985
Marital status:Single
Race:African American
Health insurance:Empire Blue Cross Blue Shield
Source of information: 
Reliability of source of information: 
PRESENT HEALTH HISTORY/ILLNESS (20 points)P.B. states that she is in good health, has a history of fibroids, and ovarian cysts. P.B. is diagnosed with anemia.
Reason for seeking care:P.B states that she is having lower abdominal pain on the right side, cramping and vaginal bleeding.
Health patterns:P.B states that she eats a balanced healthy diet and exercise 4x a week and is up to date with her all her medical.
Health goals:P.B wants to maintain her weight at 130 and get into  shape to run the marathon.  P.B.  verbalize that continues to follow up with her GYN about her fibroids and her ovarian cysts.
HEALTH BELIEFS AND PRACTICES (15 points)P.B. believes in drinking herbal tea made by her mom if she becomes ill. P.B states that her mom makes tea for her to drink for her fibroids and she does not know what the tea consist of.
Beliefs and practices:P.B. believes in prayer when she is ill and will also inform mom of her sickness and seek medical treatment.
Factors influencing healthcare decisions:P.B. verbalize that she wants be in good health for her pregnancy, and wants to be able to take care of her mom as her mom ages.
Related traits, habits or acts:Drinks different kinds of herbal tea.
MEDICATIONS (20 points) (Please refer to your assignment guidelines.) 
Prescription medications:Loestrin 24 Fe, Iron
Over-the-counter medications:Multivitamins
Herbals:Does not recall the names of the herbs that she drinks.
PAST HISTORY (20 points) 
Childhood diseases:None
Immunizations:Up to date with all her immunizations.
Allergies:No known allergies.
Blood transfusions:None
Major illnesses:None
Labor and deliveries:None
Use of alcohol:P.B verbalize that she occasionally drinks alcohol when she goes out.
Use of tobacco:No
Use of illicit drugs:None
Mental, emotional or psychiatric problems:P.B father died in 2012 and she was depressed for a year.
FAMILY HISTORY (20 points) 
Father:Father died of a heart attack, and had heart failure.
Mother:Mother has hypertension, diabetes, osteoporosis.
Siblings:Has an older brother that served in the military and is diagnosed with PTSD.
Grandparents:P.B. does not recall her grandparents health history.
Occupational history:P.B is currently working as a social worker, working with the kids and she loves her job.
Educational level:P.B has a college degree.
Financial background:P.B. verbalize she is currently working towards a promotion to increase her salary so she can a buy a home and start working on building a family.
Significant others:P.B verbalize she is dating and not in a serious relationship.
Support systems:P.B. verbalize her mother is her support system.
Ethnicity and culture:P.B is of Haitian descent.
Physical and social characteristics that influence healthcare decisions:P.B. verbalize that with all the technology and health promotion, she wants to actively try and live a healthy lifestyle. P.B wants to start getting prepared physically and mentally because she wants to have children in a few years.
SPIRITUALITY (5 points) 
Religious and spiritual needs:P.B is catholic and goes to church every Sunday.
SELF-CONCEPT (5 points) 
View of self-worth:She has a high-self esteem
Future plans:P.B. verbalize that she wants to own a home, get married and have children.
REVIEW OF SYSTEMS (20 points) (Please refer to your assignment guidelines and Chapter 4 of your text. This is not a physical examination.) 
Skin, hair, nails:P.B. complains that her skin is very dry during winter.
Head, neck, related lymphatics:P.B denies having any issues with head, neck and lymphatics.
Eyes:P.B just started wearing glasses this month due to being near sighted.
Ears, nose, mouth, and throat:P.B denies having any issues with ears, nose and throat., except when she has a cold.
Respiratory:P.B denies having any problem with respiratory.
Breasts and axillae:P.B verbalize breasts been very tender for the past month.
Cardiovascular:P.B denies having any problem with cardiovascular.
Peripheral vascular:P.B denies having any problem with peripheral vascular.
Abdomen:P.B verbalize that she is having pain in her abdomen on her right side of the body and is not relieved with medication.
Urinary:P. B denies having any problem with urinary.
Reproductive:P.B verbalize that she missed her menstrual cycle and is about 2 weeks late but is afraid to take a pregnancy test but is scheduled to go to her GYN appointment on 3/20/17.
Musculoskeletal:P.B denies having any problem with musculoskeletal.
Neurologic:P.B denies having any neurological problems.


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