Complete Health History and Examination Assignment NUR3069- Advanced Health Assessment Miami Dade College- Medical Campus I. Biographical data: Name (Initials only): ________________________________ Age: ________________________________ Gender: M or F ________________________________ Birthplace: ___ (City/Country) ________________________________ Marital Status: ________________________________ Occupation: ________________________________ Race/ ethnic origin: ________________________________ Employer________________________________ Accompanied by, or, significant other: ________________________________ Source and reliability of information: ________________________________ Source of referral________________________________ Reason for seeking care: ________________________________ Present health or HPI (if applicable): Present Illness (if applicable): ________________________________ Time of onset: ________________________________ Type of onset: ________________________________ Severity: ________________________________ Radiation: ________________________________ Time Relationship: ________________________________ Duration: ________________________________ Course: ________________________________ Association: ________________________________ Source of relief: ________________________________ Source of aggravation: ________________________________ II. Past Medical History (PMH): General State of Health: ____________________________ Childhood Illnesses: _______________________________ Childhood Vaccinations: ___________________________ Adult Illnesses: ___________________________________ Past Surgeries: _________________________________ Past Hospitalizations: ______________________________ Psychiatric Disorders Diagnosed: _____________________ III. Current Health Status: Current Medications: (OTC, PRN’s and Prescribed) ______ Allergies: (Food, Meds or Environment) ________________ Drugs: ________________________________ Alcohol: ________________________________ Tobacco: ________________________________ Diet: (24-hour totals) _________________________________ Screening tests: _________________________________ Sleep patterns: ________________________________ Exercise & Leisure activities: ___________________________ Environmental hazards: ________________________________ Safety measures: _ ____________________________________ IV. Family History: Known genetic problems: ________________________________ Heart disease: ________________________________ Allergies: ________________________________ Hypertension: ________________________________ Asthma: ___________________ Stroke: _____________________ Obesity: ___________ Diabetes: ________________________________ Alcoholism: ________________ Blood disorders: _______________ Mental illness: ________________ Breast cancer: _________________ Kidney disease: _______________ Cancer (other): __________________ Seizure disorde.

1. Complete Health History and Examination Assignment
NUR3069- Advanced Health Assessment
Miami Dade College- Medical Campus
I. Biographical data:
Name (Initials only): ________________________________
Age: ________________________________
Gender: M or F ________________________________
Birthplace: ___ (City/Country)
________________________________
Marital Status: ________________________________
Occupation: ________________________________
Race/ ethnic origin: ________________________________
Employer________________________________
Accompanied by, or, significant other:
________________________________
Source and reliability of information:
________________________________
Source of referral________________________________
Reason for seeking care: ________________________________
Present health or HPI (if applicable):
Present Illness (if applicable):
________________________________
Time of onset: ________________________________
Type of onset: ________________________________
Severity: ________________________________
Radiation: ________________________________
Time Relationship: ________________________________

2. Duration: ________________________________
Course: ________________________________
Association: ________________________________
Source of relief: ________________________________
Source of aggravation: ________________________________
II. Past Medical History (PMH):
General State of Health: ____________________________
Childhood Illnesses: _______________________________
Childhood Vaccinations: ___________________________
Adult Illnesses: ___________________________________
Past Surgeries: _________________________________
Past Hospitalizations: ______________________________
Psychiatric Disorders Diagnosed: _____________________
III. Current Health Status:
Current Medications: (OTC, PRN’s and Prescribed) ______
Allergies: (Food, Meds or Environment) ________________
Drugs: ________________________________

3. Alcohol: ________________________________
Tobacco: ________________________________
Diet: (24-hour totals) _________________________________
Screening tests: _________________________________
Sleep patterns: ________________________________
Exercise & Leisure activities: ___________________________
Environmental hazards: ________________________________
Safety measures: _ ____________________________________
IV. Family History:
Known genetic problems:
________________________________
Heart disease: ________________________________
Allergies: ________________________________
Hypertension: ________________________________
Asthma: ___________________
Stroke: _____________________
Obesity: ___________
Diabetes: ________________________________
Alcoholism: ________________
Blood disorders: _______________
Mental illness: ________________
Breast cancer: _________________
Kidney disease: _______________
Cancer (other): __________________
Seizure disorder: _______________
Sickle Cell: ___________________
Arthritis:.______________
V. Genogram: (Attached)

4. VI. Review of Systems: (3 negatives needed)
General: _____________
Skin___________________
Neurological: ________________________________
Eyes: ________________________________
Ears: ________________________________
Nose/Sinuses:
_____________________________________________________
____________
Mouth/Throat:
_____________________________________________________
___________
Neck:
_____________________________________________________
__________________
Respiratory:
_____________________________________________________
_____________
Chest/Breast:
_____________________________________________________
____________
Cardiac:
_____________________________________________________
________________
Gastrointestinal:
_____________________________________________________

5. __________
Genitourinary:
_____________________________________________________
____________
Peripheral vascular:
_____________________________________________________
________
Musculoskeletal:
_____________________________________________________
__________
Hematological:
_____________________________________________________
___________
Endocrine:
_____________________________________________________
______________
Psychiatric:
_____________________________________________________
______________
Physical Examination:
Vital Signs:
Temperature (F°): _____________ (Oral/tympanic/rectal) Pulse:
__________________ (artery?)

6. Resp Rate _________________ Weight: ________________
Height: ________________
BMI: ______________Physical appearance: ________________
Level of Consciousness: ___________________ Facial
features: ____________________ General:
_____________________________________________________
_______________
Skin:
_____________________________________________________
_________________
Neurological:
_____________________________________________________
___________
Eyes:
_____________________________________________________
__________________
Ears:
_____________________________________________________
__________________
Nose/Sinuses:
_____________________________________________________
____________
Mouth/Throat:
_____________________________________________________
___________
Neck:
_____________________________________________________

7. __________________
Respiratory:
_____________________________________________________
_____________
Chest/Breast:
_____________________________________________________
____________
Cardiac:
_____________________________________________________
________________
Gastrointestinal:
_____________________________________________________
__________
Genitourinary:
_____________________________________________________
____________
Peripheral vascular:
_____________________________________________________
________
Musculoskeletal:
_____________________________________________________
__________
Hematological:
_____________________________________________________
___________
Endocrine:
_____________________________________________________

8. ______________
Plan or F/U
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_________________