NURSING MS C350 Comprehensive Health Assessment Documentation Form_0416/Patient Initials SF

Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:__________ Patient Information Patient Initials SF Age 48 Sex M Chief Complaint Patient denies any acute complaint. Pt is requesting a comprehensive health assessment as part of his annual physical examination. History of Present Illness (HPI) HPI: no specific complaints Location: none Quality: none Severity: none Timing: none Setting: none Remitting / exacerbating factors: none Associated manifestations: none 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Patient reports no current medications Allergies No known drug allergies  Medical HX (PMH) Childhood Chicken pox (unknown age). Denies any other illnesses. Adult Denies any acute or chronic medical conditions Surgical Jaw surgery age 19 (atraumatic) Gallbladder removed mid-30s (no complications) Ob/Gyn N/A Psychiatric Patient denies any psychiatric illness; denies depression; denies loss of interest in normal activities Vaccinations Flu Date: 08/2018 Pneumovax Date: has not received Tetanus Date: 06/2014 Family HX (specify family member affected/age at death) Mother and father both still living, both in good health. Maternal grandmother died from a stroke in her 60s. Denies any history of cardiac disease, HTN or diabetes in family.