Advanced Nursing Practice Field Experience
Comprehensive Health Assessment Documentation Form
Date:__________
Patient Information
Patient Initials
Age
Sex
Chief Complaint
History of Present Illness (HPI)
7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations
Medications
Allergies
Medical HX (PMH)
Childhood
Adult
Surgical
Ob/Gyn
Psychiatric
Vaccinations
Flu
Date:
Pneumovax
Date:
Tetanus
Date:
Family HX (specify family member affected/age at death)
Social HX
HTN
DM
Ca
MI/CAD
CVA
TB
Renal dz
Thyroid dz
Suicide
Alcoholism
Substance abuse
Born in:
Education:
Occupation:
Family situation:
Interests/Hobbies:
Review of Symptoms (ROS)
List findings, or check as negative. (If you have a positive finding, then describe its seven attributes in the HPI or PMH)
Concerning Symptom
Findings
General
Wgt Δ; weakness; fatigue; fevers
Skin
Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails
Head
Headache; head injury; dizziness
Eyes
Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma
Ears
Hearing Δ; tinnitus; earaches; infections; discharge
Nose/
Sinuses
Colds; congestion; discharge; itching; hay fever; nosebleeds
Throat
Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse
Neck
Lumps; swollen glands; goiter; pain; neck stiffness
Breasts
Lumps; pain; discomfort; nipple discharge
Pulmonary
Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains
Cardiac
Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema
G/I
Appetite...