Comprehensive Health Assessment Form

 
 
(50 points)
Health History(5 pts total)
Biographical data: (1 pts)
No name or initial required
Age: : . ____Cohab.
Birth date: _____________________ Number of dependents: ___________________
Educational level: ________________________ Gender: _____F _____ M _____Other
Occupation (current or, if retired, past): ______________________________________
Ethnicity/nationality: _____________________
Source of history (who gave you the information and how reliable is that person): _______________________________________________________________________
Present health history: (4 pts)
Current medical conditions/chronic illnesses:
Current medications:
Medication/food/environmental allergies:
Past health history:(10 pts total)
Childhood illnesses: Ask about history of mumps, chickenpox, rubella, ear infections, throat infections, pertussis, and asthma.
Hospitalizations/Surgeries:Include reason for hospitalization, year, and surgical procedures.
Accidents/injuries: Include head injuries with loss of consciousness, fractures, motor vehicle accidents, burns, and severe lacerations.
Major diseases or illnesses: Include heart problems, cancer, seizures, and any significant adult illnesses.
Immunizations (dates if known):
Tetanus _______ Diphtheria ________ Pertussis ________ Mumps ________
Rubella _______ Polio _____________ Hepatitis B ______ Influenza _______
Varicella ______ Other ____________________________________________
Recent travel/military services: Include travel within past year and recent and .
Date of last examinations:
Physical examination _________ Vision ___________ Dental ___________
Family History (Genogram)(10points)
Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any major health issues, and, if indicated, cause and age at death Present as a genogram.
Review of Systems(12 points total) Be sure to ask about symptoms specifically.
General health status (1 pt): Ask about fatigue, pain, unexplained fever, night sweats, weakness, problems sleeping, and unexplained changes in weight.
Integumentary (1 pt):
Skin:Ask about change in skin color/texture, excessive bruising, itching, skin lesions, sores that do not heal, change in mole. Do you use sun screen? How much sun exposure do you experience?
Hair: Ask about changes in hair texture and recent hair loss.
Nails: Ask about changes in nail color and texture, splitting, and cracking.
HEENT (2 pts):
Head:Ask about headaches, recent head trauma, injury or surgery, history of concussion, dizziness, and loss of consciousness.
Neck: Ask about neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the neck.
Eyes: Ask about change in vision, eye injury, itching, excessive tearing, discharge, pain, floaters, halos around lights, flashing lights, light sensitivity, and difficulty reading. Do you use corrective lenses (glasses or contact lenses)?
Ears: Ask about last hearing test, changes in hearing, ear pain, drainage, vertigo, recurrent ear infections, ringing in ears, excessive wax problems, use of hearing aids.
Nose, Nasopharynx, Sinuses: Ask about nasal discharge, frequent nosebleeds, nasal obstruction, snoring, postnasal drip, sneezing, allergies, use of recreational drugs, change in smell, sinus pain, sinus infections.
Mouth/Oropharynx: Ask about sore throats, mouth sores, bleeding gums, hoarseness, change voice quality, difficulty chewing or swallowing, change in taste, dentures and bridges.
Respiratory (1 pt):
Ask about frequent colds, pain with breathing, cough, coughing up blood, shortness of breath, wheezing, night sweats, last chest x-ray, PPD and results, and history of smoking.
Cardiovascular (1 pt.):
Ask about chest pain, palpitations, shortness of breath, edema, coldness of extremities, color changes in hands and feet, hair loss on legs, leg pain with activity, paresthesia, sores that do not heal, and EKG and results.
Breasts (1 pt.):(Remember men have breasts too)
Ask about breast masses or lumps, pain, nipple discharge, swelling, changes in appearance, cystic breast disease, breast cancer, breast surgery, and reduction/enlargement. Do you perform BSE (when and how)? Date of last , and mammograms and results.
Gastrointestinal (1 pt.):
Ask about changes in appetite, heartburn, gastroesophageal reflux disease, pain, nausea/vomiting, vomiting blood, jaundice, change in bowel habits, diarrhea, constipation, flatus, last fecal occult blood test and colonoscopy and results.
Genitourinary (1 pt.):
Ask about pain on urination, burning, frequency, urgency, incontinence, hesitancy, changes in urine stream, flank pain, excessive urinary volume, decreased urinary volume, nocturia, and blood in urine.
Female/male reproductive (1 pt.):
Both:Ask about lesions, discharge, pain or masses, change in sex drive, infertility problems, history of STDs, knowledge of STD prevention, safe sex practices, and painful intercourse. Are you current involved in a sexual relationship? If yes, heterosexual, homosexual,, bisexual? Number of sexual partners in the last 3 months. Do you use birth control? If yes, method(s) used.
Female: Ask about menarche, description of cycle, LMP, painful menses, excessive bleeding, irregular menses, bleeding between periods, last Pap test and results, painful intercourse, pregnancies, live births, miscarriages, and abortions.
Male: Ask about prostate or scrotal problems, impotence or sterility, satisfaction with sexual performance, frequency and technique for TSE, and last prostate examination and results.
Musculoskeletal (1 pt.):
Ask about fractures, muscle pain, weakness, joint s

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