1

Running head: COMPLETE HEALTH HISTORY

Complete Health History Assessment

Veronica Alvarez

Azusa Pacific University

UNRS 220 Health Assessment

Prof. Joy David

March 22, 2017

 2
COMPLETE HEALTH HISTORY
Complete Patient History

Examiner’s Name: Veronica Alvarez Patient initials: J.J.

Patient Identification

Age: 26

Race/Ethnicity: African American

Sex: Female

Occupation: LVN

Marital Status: Single

City of Residence: Inglewood, CA

Children: None

Others living in the home: Patient states she lives with her maternal grandmother, and

female cousin.

Birthplace: Inglewood, CA

Birthplace of parents: Mother born in Los Angeles, CA. Father was born in North

Carolina. Patient states she does not know what city father was born in.

Education: LVN Certification

Source of information and Reliability

Patient herself, whom seems reliable.

Reason for Seeking Care

“Painful blister near right side of outer mouth for 2 days”.

History of Present Illness

 3
COMPLETE HEALTH HISTORY
26-year-old African American presented to Urgent Care seeking medical care for “painful

blister near right side of outer mouth for 2 days”. Patient denies history of skin disease. Patient

denies eczema, psoriasis, hives. Patient denies pigment or color change. Patient denies excessive

dryness or moisture, pruritus. Patient denies excessive bruising, rash or lesion. Patient denies no

known drug or food allergies. Onset noted 1/27/17 sensation of itchiness and tingling to right-

side outer area per patient. Patient states that 1/28/17 she noticed a small blister. Today patient

states that the blister increased in size from 1 cm to 2 cm. Patient also stated she noticed redness

around the blister. Patient states blister is painful when she touches it and located on the right

side her mouth. Patient denies past events of similarity. Patient denies blisters on mouth

occurring before in the past. Patient states that she avoids chewing food on the right side of

mouth to avoid pain from contact with salty or hot foods. Patient also stated that direct contact

touch causes the sharp-like pain. Patient denies radiation of pain in other parts of the body.

Patient also states that nothing helps relieve her symptoms. Patient stated that she noticed the

tingling and itchy sensation x 2 days ago when she was cooking hamburgers on the stove top.

Associated symptoms per patient include fever of 102.0 and feeling of tiredness.

Past Health

General Health

Patient states that she is in “fairly good health and rarely gets sick”.

Childhood Illnesses

Patient denies history of childhood illnesses such as measles, mumps, rubella, and

chickenpox. Patient also denies having pertussis and strep throat.

Accidents or Injuries
 4
COMPLETE HEALTH HISTORY
Patient denies history of accidents or injuries. Patient denies any auto accidents, head

trauma, fractures, burns or penetrating wounds.

Serious or Chronic Illness

Patient denies history of serious or chronic illnesses. Patient denies having asthma,

depression, diabetes, hypertension, heart disease, human immunodeficiency virus infection,

hepatitis, sickle-cell anemia, cancer, and seizure disorder.

Hospitalizations

Patient denies history of and or recent hospitalizations.

Operations

Patient denies history of surgeries and operations.

Obstetric History

Gravida: None Term: None Preterm: None

Ab/incomplete: None Children Living: None

Patient denies history of pregnancy. Patient denies abortions or miscarriage

Immunization History

DTaP Date: 12/12/16

Pneumonia Date: 11/30/16

Influenza Date: Patient refused

Hepatitis Type: B Date: 06/11/98, 07/23/99, 11/08/01

MMR Date: 07/09/91, 08/30/95

 5
COMPLETE HEALTH HISTORY
Rotavirus Date: 2/03/14

Hib Date: 07/09/91, 09/24/91

Varicella Date: 12/22/16

IPV Date: 08/13/90, 10/08/90, 12/10/90, 03/27/92

TB Date: 11/21/16, 12/22/16

Last Examination 12/22/16

Diagnostic/Laboratory Tests: Patient states she had a CBC, CMP done. All lab values

within normal range per patient.

Current Medications

Patient denies use of prescribed medications. Patient denies use of over the counter

medications. Patient denies the use of herbal supplements.

Allergies

Patient denies no known drug or food allergies.

Family History

See end of report.

Review of Systems

Patient states she is 160 lbs. Patient denies weight gain or loss. Patient denies fatigue,

weakness, malaise, fever, chills, and night sweats.

Integument

See HPI.

Health promotion: Patient states practice of hygienic skin care. Patient states she often applies

sun screen and wears sun hats when exposed to the sun for long periods of time.
 6
COMPLETE HEALTH HISTORY
Head

Patient denies any recent or frequent headaches. Patient denies dizziness, syncope, or

near-fainting episodes. Patient denies any recent head trauma.

Health Promotion: Patient states she wears protective head gear when biking.

Neck

Patient denies any pain. Patient denies any difficulty in range of motion of neck. Patient

denies any lumps or swelling. Patient denies any obvious enlargement or tender noted. Patient

denies goiter.

Health Promotion: Patient states she checks her neck daily for any obvious enlargements.

Ears

Patient denies any recent earaches, infections, or discharge. Patient denies hearing

impairment or difficulties. Patient denies tinnitus or vertigo.

Health Promotion: Information not avoid sticking foreign objects into ear. Method of correct

cleaning care. Effects of loud noises, protection from environmental exposures. Patient states she

wears ear plugs when in loud environments. Patient states she does not use headphones at loud

volumes.

Eyes

Patient denies blurred vision. Patient denies difficulties with vision. Patient denies use of

corrective lens or contacts. Patient denies history of eye disease such as cataracts, glaucoma.

Patient denies eye. Patient denies swelling of upper and lower eye lids. Patient denies discharge

or excessive tearing from eyes.

Health promotion. Patient states she washes her hands always before touching eyes. Patient

states she wears protective sun glasses to avoid damage to eyes.

 7
COMPLETE HEALTH HISTORY
Nose and Sinuses

Patient denies discharge. Patient denies recent colds, sinus pain, nasal obstruction. Patient

denies recent nosebleeds. Patient denies allergies or hay fever. Patient denies any change in sense

of smell.

Health Promotion: Patient states she uses air humidifier to promote clean air for respiration.

Patient states she frequently cleans home of dust or pollen to avoid allergic reactions or irritants.

Oropharynx

Patient denies recent mouth pain. Patient denies any recent lesions of mouth. Patient

denies recent bleeding of mouth or gums. Patient denies toothache, tooth decay, or missing

teeth. Patient denies dysphagia and hoarseness or voice change. Patient denies any changes in

taste.

Health Promotion: Patient states she brushes her teeth twice a day and flosses. Patient states

visits her dentist every 6 months for deep cleaning and care.

Respiratory

Patient denies shortness of breath. Patient denies cough, sputum, hemoptysis, toxin or

pollution exposure. Patient denies history of lung diseases such as asthma, emphysema,

bronchitis, pneumonia, or tuberculosis.

Health Promotion: Air humidifier in home to reduce inhalation of pollen or dust. Encourage

follow up with Primary care for annual physical. Patient states she had gets annual TB test

12/22/16.

Cardiovascular

Patient denies history of cardiac diseases. Patient denies history of hypertension, heart

murmur, coronary artery disease and anemia. Patient denies chest pain, pressure, palpitation, and
 8
COMPLETE HEALTH HISTORY
tightness of chest. Patient denies cyanosis, dyspnea on exertion. Patient denies orthopnea,

paroxysmal nocturnal dyspnea, nocturia, and edema.

Health promotion: Patient states she eats a healthy, low cholesterol diet. Exercise 30-60 minutes

a day. Cholesterol lab value monitoring.

Peripheral vascular

Patient denies swelling, numbness, tingling, and coldness of bilateral lower extremities.

Patient denies discoloration of hands or feet. Patient denies bluish, red, pallor discoloration

around feet or ankles. Patient denies varicose veins or complications, intermittent claudication,

thrombophlebitis, ulcers.

Health Promotion: If work requires long periods of standing or sitting, apply ted hose to help

prevent blood clots. Walk around to help circulate blood flow. Patient states she attempts to walk

around when sitting for long periods of time.

Breasts

Patient denies lumps or swelling of breast. Patient denies any discharge from nipples.

Patient denies bilateral breast pain. Patient denies any history of breast disease. Patient denies

any surgical history to breast.

Health Promotion: Self-examination of breast, method and best time to assess. Patient states she

performs self-breast exams after her menstrual cycle.

Gastrointestinal

Patient denies changes in appetite. Patient denies food intolerance, heartburn, indigestion,

pain with eating, abdominal pain, pyrosis. Patient denies nausea, vomiting, diarrhea. Patient

denies history of abdominal diseases such as appendicitis, gallstones, ulcers, jaundice, colitis.
 9
COMPLETE HEALTH HISTORY
Patient denies black stools, flatulence, bowel movement frequency, rectal bleeding, and rectal

conditions.

Health Promotion: Encourage high fiber diet if patient feels constipated. Use of antacids or

laxatives may also help.

Genitourinary

Patient denies history of urinary diseases such as kidney stones, urinary tract infections,

or kidney stones. Patient denies dysuria, polyuria or oliguria. Patient denies hematuria, hesitancy

or straining. Patient denies foul smelling odor of urine. Patient denies abnormal vaginal

discharge or bleeding. Patient denies pain of suprapubic area, flank pain, groin region, and low

back.

Health Promotion: Kegel exercises. Vaginal examinations done by OB/GYN doctor. Increase

water intake. Good vaginal hygiene.

Reproductive History

Patient states she in a monogamous relationship. Patient states she is sexually active.

Patient denies contact with partner with sexually transmitted diseases such as gonorrhea,

chlamydia, herpes, venereal warts, HIV/AIDS, or syphilis. Patient denies dyspareunia. Patient

states that she started her menses at the age of 13. Patient states that last menstrual period was

1/14/17. Patient states that last pap smear was 12/22/17. Patient states she does experience

premenstrual pain. Patient states that cycle is every 28 days, duration last 7 days. Patient states

she uses about 3 regular sanitary napkins a day during menses. Patient denies menorrhagia.

Patient denies vaginal itching or discharge. Patient denies menopause. Patient states that she

practices the use of condoms as contraception before sexual intercourse.

 10
COMPLETE HEALTH HISTORY
Health promotion: Encourage the use of birth control such as pills, IUD, Mirena to avoid

unwanted pregnancies. Promote safe sex practices to avoid exposure of STI, STDs, and HIV.

Promote/encourage to keep annual appointments to follow up with pap smears and STD panel

checks.

Musculoskeletal

Patient denies history of arthritis or gout. Patient denies pain or stiffness, swelling,

deformity, limitation of motion, or noise with joints. Patient denies any muscle pain, cramps,

spasms. Patient denies gait problems or with coordination. Patient denies pain, stiffness, or

limited range of motion of back. Patient denies any history of disc diseases or back surgeries.

Health Promotion: Good Body mechanics when lifting heavy objects to avoid straining back.

Use of a mechanical aid if applicable to carry and transport heavy objects to avoid back injury.

Neurological

Patient denies history if seizure disorder, stroke, syncope, black outs. Patient denies

tremors, paralysis or coordination issues. Patient denies speech impairment. Patient denies

numbness or tingling. Patient denies memory problems. Patient denies mood changes,

depression, nervousness, or hallucinations. Patient denies mental health disorders.

Health promotion: encourage support groups, mental health facilities if patient seeks help with

mental health disorders.

Endocrine

Patient denies history of diabetes. Patient denies history of thyroid complications,

intolerance to heat or cold, change in skin pigmentation or texture, excessive sweating. Patient

denies abnormal hair distribution, changes in weight.

 11
COMPLETE HEALTH HISTORY
Health promotion: encourage health diet. Keep annual follow up appointments to monitor basic

lab values.

Hematologic/Lymphatic

Patient denies any unusual bleedings, epistaxis, bruising, ecchymosis, petechiae, or

purpura. Patient denies enlargements of lymph nodes. Patient denies recent blood transfusions.

Health promotion: Avoid exposure to toxins or harmful agents.

Psychosocial

Patient denies cognitive impairment. Patient denies changes in mood or behavior.

Health Promotion: Healthy stable, relationships. Moderate exercise 20-30 min a day to help

relieve stress.

Functional Assessment

Self Esteem, Self-Concept: Patient states obtain her ADN degree from EL Camino

community college in 2011. Patient also stated that she received her LVN Certification from Los

Angeles Institute in August of 2012. Patient states, “I am proud of what I have accomplished, but

I do wish to return to school to obtain my RN”.

Health Promotion: Offer encouragement/ advice to patient in returning to school.

Financial Status

Patient stated that she is currently working part-time for Los Angeles Institute in Los

Angeles as LVN instructor. Patient states that her annual income went from $54,000 to $27,000

because she returned to school full time. Patient states that financially and emotionally she is not

stressed. Patient states she currently has United Healthcare insurance with her job. Patient stated

that she is not financially stressing because she will apply for student loans. Patient also stated

that she still lives with grandmother, so she does not have to worry about rent.
 12
COMPLETE HEALTH HISTORY
Health Promotion: Methods of coping with stress. Offer information of scholarship

opportunities.

Value-belief system

Patient states that she was raised Christian. Patient states she considers herself to be

spiritual and religious. Patient stated that her religious background influences her spiritual beliefs

of morality and ethics. Patient states she attends church every Sunday with her family.

Self-care behaviors

Patient states that she maintains a healthy diet to help maintain her weight. Patient states

she shops as method to reduce stress. Patient states she “enjoys going to the nail salon to get her

toes done”. Patient states she uses “the best of the skin care products” to keep her skin

moisturized.

Activity/Exercise

Patient states that she works part-time and goes to school full time. Patient stated that

Monday afternoons she works from 1300-1500 at work, where majority of the time she may be

sitting. Patient states she goes to the gym Monday nights for 1 hour cardio. Patient states she

attends school Tuesday and Wednesday from 0900 to 1800, she is sitting majority of the time.

Patient states Thursday she goes to the gym in the morning at 0900 for an hour. Patient states

Friday she attends training from 0630 to 0730, patient stated she is constantly on her feet

throughout those 12 hours. Patient states on the Saturdays she works from 1200-1600. Patient

states she spends her time walking and monitoring her students. Patient states on Sunday she

relaxes to do homework and study, little activity/exercise is done.

Independent or needs assistance with ADLs

Patient states she is independent and does not require assistance with ADLs.
 13
COMPLETE HEALTH HISTORY
Leisure activities

Patient states “she enjoys spending time with her boyfriend and going out on dates to

help relieve her stress”. Patient also stated that she enjoys shopping to help relieve tension from

work and school.

Exercise pattern

Patient states that she does not exercise daily. Patient states that she exercises about 3

days a week for about an hour each time. Patient states that she feels like she does not get enough

exercise. Patient states that if she had more time she would participate in strength and flexibility

exercises.

Health Promotion: Stretch before and after work out. Eat healthy diet.

Sleep/Rest

Patient states she requires 8 hours of sleep a night. Patient states she sleeps 7 to 9 hours a

night. Patient states she typically feels rested. Patient states she sleeps by 2130 and awakens at

0800 every day. Patient denies sleep interruptions. Patient states she listens to music when she

cannot sleep and it typically helps her sleep. Patient states she if she is able she will take a 1 hour

nap at home.

Nutrition/Elimination

24-hour diet recall

Patient states on a typical day at 0900 she will eat 2 whole eggs, 2 slices of wheat bread,

with 16 oz. of milk, 2% nonfat. Lunch at 1200: patient stated she ate 6-inch turkey sandwich

with 2 slices of tomatoes, lettuce, pickles with mustard on 2 slices of wheat bread. 1 small bag of

potato chips, and 16 oz. bottle of water. Dinner: Patient ate 4 oz. steak, baked potato, and 5

asparagus with 20 oz. cup of lemonade. Patient denies food allergies. Patient states she likes
 14
COMPLETE HEALTH HISTORY
seafood, chicken, and rice. Patient states she does not like vegetables, but she tries to eat them.

Patient states this is a typical menu pattern daily. Patient denies loss of appetite, taste, and smell.

Patient states she has a good appetite daily. Patient states she either prepares her meals herself or

she buys fast food. Patient states she does not always have time to prepare her food, but she

attempts to do it as much as possible. Patient states she either eats with her boyfriend or

grandmother. Patient states she financially supports her eating expenses. Patient states she

considers herself to be overweight by 15 lbs.

Health Promotion: Encourage a low-carb, high protein diet. Encourage patient to eat more

vegetables and adequate exercise. Patient states she tries to eat less carbs and more protein in

diet.

Interpersonal Relationships/Resources

Patient states that she is tertiary source of income at home. Patient states that her

grandmother primarily cares for the house and bills. Patient states she has a healthy, stable

relationship with her grandmother and cousin. Patient states that they have a relationship. Patient

states that her grandmother is a very important figure in her life. Patient states that she has one

best friend from childhood, who she can share her thoughts and feelings with. Patient states that

she enjoys volunteering for church events, when she can. Patient states when she needs help she

can go to her grandmother or cousin. Patient denies recent family crisis or changes. Patient states

she gets support from her family and friends. Patient states she gets about 4-6 hours a day by

herself when she needs to study and she finds it relaxing.

Coping and Stress Management

 15
COMPLETE HEALTH HISTORY
Patient states that she recently started nursing school in January and the thought of school

assignments is stressing her out. Patient states she uses the gym to relieve stress. Patient states

after “she gets in a good 20-minute run, she feels relaxed”.

Personal Habits

Patient states she drinks about 40 oz. of Pepsi twice a week. Patient states she is reducing

her soda intake. Patient denies smoking. Patient states she drinks occasionally, patient states that

last time she drank was 1/01/17, patient states she drank 8 oz. of coca cola mixed with 1 oz. of

rum. Patient states that out of the past 30 days, she drank that 1 time. Patient denies a drinking

problem. Patient denies use of recreational or illegal drugs. Patient denies use of marihuana,

heroin, cocaine, barbiturates, amphetamines, LSD. Patient denies treatment of drug abuse.

Patient denies family of substance abuse, suicide, mental illness, addiction, or disruptive family.

Environment/Hazards

Patient states she lives in 3 bedrooms, 2 bath house with her grandmother and female

cousin in Compton, LA. Patient states that neighborhood has improved from previous issues of

gang violence. Patient states she does not feel unsafe in her neighborhood. Patient states her

house is provided with adequate heat, water, gas, and electricity. Patient states that she owns and

drives her own personal 2015 mustang. Patient denies involvement in community services

besides church gatherings. Patient states she not exposed to hazardous materials at work. Patient

states she always uses seatbelts when she drives. Patient states that recently travelled to Iceland

in December of 2016. Patient denies residence in other countries. Patient denies involvement

with US military.

Intimate Partner Violence

 16
COMPLETE HEALTH HISTORY
Patient states she has been involved in a monogamous relationship for 2 years. Patient

denies abuse, negligence. Patient states her relationship with her boyfriend is healthy. Patient

denies feelings of being taken advantage of.

Occupational Health

Patient states she currently works as an LVN for Los Angeles Institute since Aug 2016.

Patient stated that she worked Alamitos West Home Health from 2013 to 2016. Patient states she

currently enjoys her current job, Patient states she is happy with the hours from 1200 to 1600, 2-

3 days a week. Patient states that the students can stress her out, she says monitoring 18-20

students a day can be difficult. Patient states she had requested additional help during her skills

lab. Patient states she exposed to sharp instruments such as sterile IV needles. Patient states there

is hazardous material waste and needle water containers to avoid blood exposure and need stick

injuries.

Perception of Own Health

Patient states she is in good health. Patient states she rarely gets sick. Patient states she

hardly ever needs to go see her doctor. Patient states she in good health. Patient describes herself

an average height, average size. Patient states she feels “she needs a smaller waist and toned

abdomen”. Patient describes her glutes as her best part and abdominal area as her worst part.

Patient described herself as an upbeat, friendly, social person. Patient states she her strengths are

she sets a goal and she will achieve her goal. Patient states she is weak when it comes to

improving her image. Patient states that food makes her weak. Patient denies concerns now.

Patient states she expects to empower her will to eat healthier. Patient states her health goals to

get in shape and strengthen her core and legs. Patient states she expects the nurses and physician
 17
COMPLETE HEALTH HISTORY
to keep all information private and not violate her rights as patient. Patient states she expects the

nurses and physician to carry a professional relationship with clients.

 18
COMPLETE HEALTH HISTORY
Genogram
 19
COMPLETE HEALTH HISTORY

References
 20
COMPLETE HEALTH HISTORY
American Psychological Association. (2010). Publication manual of the American

Psychological Association (6th ed.). Washington, DC: Author.

Jarvis, C. (2016). Physical examination and health assessment (7th ed.). St. Louis, MO:

Mosby Elsevier.

Jarvis, C. (2016). Student laboratory manual for physical examination and health

assessment (7th ed.). St. Louis, MO: Mosby Elsevier.