NURS 3308
Health History Template
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Health History
Date: 5/25/2020
I.
Student: Sydney Short
A. Biographic Data:
Birthplace: Longview
Lab Day/Time: Thursday 9am-12pm
Patient’s initials: B.S.
Age: 24
Where raised: Longview
Language(s) spoken: English
Primary language: English
Race(s): Caucasian (Non-Hispanic)
Ethnic origin: Irish & Native American
Marital Status: Single
Gender: Male
Occupation: Student
Religion: Agnostic
Subcultures patient is a member of: N/A
B. Source and Reliability: Patient himself, who seems reliable.
II. Reason for seeking care (Chief Complaint): Patient noticed a lump in lower right testicle and complained of
slight pain and sensitivity.
III. History of Present Illness (or Present Health):
Symptom analysis of the 8 variables
1. Body location: Right genital region
2. Quality: Sensitivity and throbbing pain in genital region
3. Quantity (scale 0-10): 3/10 pain
4. TimingOnset: The first symptom appeared four days ago, pain began last night.
Duration: Intermittent pain.
Frequency: Lump has been consistent & has not grown; pain onset every 3-4 hours.
5. Setting: The patient noticed the symptom upon waking, 4 days ago.
6. FactorsAggravating: Wearing tight clothing, hot water, physical activity.
Alleviating: Cool compress, avoiding physical activity.
7. Associated factors: N/A
8. Patient’s perception of the symptoms: Patient states that physical activity has decreased significantly
since the onset of these symptoms.
IV. Past health:
1. Childhood illnesses with age(s): Influenza at age 7, but otherwise healthy childhood.
2. Accidents and injuries: Dog attack at age 11; Athletic facial injury at age 13; Sprained ankle at age 19.
3. Serious or chronic illnesses: N/A
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Health History Template
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4. Hospitalizations: N/A
5. Surgeries: Tonsillectomy, Adenoidectomy, Wisdom Teeth Removal
6. Obstetric history: N/A
7. Immunizations-Childhood vaccines: All vaccines have been up to date.
Hepatitis B:
Tetanus:
Flu:
Pneumonia vaccine:
TB Skin Test: 2/14/20 Other:
8. Last Exam DatePhysical: 2/14/2020
Dental: 1/23/2020
Vision: 7/18/2020
Hearing: N/A
9. Allergies and reaction to eachThe patient reports no allergies or allergic reaction.
10. Current Medications (Add or delete rows as needed)
Medication (Include
OTC, herbal or
vitamins)
Fish Oil
Why taking
Dose
Route
(how taken)
Promote heart
health
2,000mg
Oral
Frequency
(how often
taken)
Twice a
week
How long
taken
Classification
7 years
OTC Vitamin
V. Family History:
1.
Heart Disease: Maternal Grandfather
High blood pressure: Maternal Grandfather
Stroke: N/A
Diabetes (Type I or II): Maternal Grandfather (Type II)
Blood disorders: N/A
Cancer (breast, colon, other): Maternal Great Aunt (colon cancer), Great Aunt & Uncle (unknown
cancer), Paternal Aunt (breast cancer)
Sickle cell anemia: N/A
Arthritis: Maternal Grandmother (rheumatoid arthritis)
Asthma: Brother
Other respiratory disorders: Maternal Grandfather (COPD)
Drug or alcohol dependence: Maternal side (alcohol dependence)
Obesity: N/A
Mental illness: Paternal
Seizure disorder: N/A
Kidney disease: N/A
Tuberculosis: N/A
Other: Maternal Cousin (Parkinson’s), Maternal Grandmother (Parkinson’s)
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Health History Template
VI. Review of Systems:
General overall health status: 1. Weight constant
2. No fatigue or lethargy
3. No sweating
Skin, Hair & Nails: 1. Dermatitis on elbow
2. No excessive sweating
3. No bruising
Health Promotion: Cream from dermatologist used for dermatitis
Head: 1. No headaches; migraines once a month
2. No dizziness or vertigo
3.
Eyes: 1. Near-sighted vision
2. No discharge from eyes
3.
Health Promotion: Currently wears glasses/contacts
Ears: 1. No earaches
2. No infections
3.
Health Promotion:
Nose and Sinuses: 1. Allergies in nose
2. No obstructions
3.
Mouth and Throat: 1. No sore throat
2. No mouth pain or bleeding gums
3.
Health Promotion:
Neck: 1. No pain or limitation of motion
2.
3.
Breast: 1. N/A
2.
3.
Health Promotion (include for male as well):
Axilla: 1. No tenderness or rash
2.
3.
Respiratory System: 1. No chest pain
2. No Hx of respiratory disease
3.
Health Promotion:
Cardiovascular: 1. No chest pain
2. No CV problems
3.
Health Promotion:
Peripheral Vascular: 1. No edema
2. No numbness
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Health History Template
3.
Health Promotion:
Gastrointestinal: 1. Normal appetite
2. No GI upset or cramps
3.
Health Promotion:
Urinary System: 1. Urinate normal frequency
2. Normal color to urine
3.
Health Promotion:
Male or Female Genital System: 1. Testicular pain present: 3/10
2. Lump on right testicle.
3. Redness present on right testicle.
Health Promotion (Male or Female): Perform testicular self-examination daily since symptoms have
arose.
Sexual health: (Deferred for this assignment)
Musculoskeletal: 1. Hx of arthritis in family
2. No muscle pain
3.
Health Promotion:
Neurologic: 1. No Hx of seizures
2. Normal coordination, no disorientation
3.
Health Promotion:
Hematologic: 1. Normal bleeding
2. No blood transfusion reactions
3.
Endocrine: 1. No hx of diabetes
2. No change in skin pigmentation
3.
Mental Status:
Have you ever been diagnosed with depression, anxiety or mental illness? If so, describe.
No, patient has not been diagnosed with mental illness.
VII. Functional Assessment:
Self-esteem, self-concept
Education: Current Full-Time Student; Senior in University
Financial Status: Dependent; Income adequate for lifestyle & health concerns
Value/Belief System: N/A
Activity/Exercise
ADLs: Exercise, stretch, yoga, walking
Leisure Activities: Video games, reading
Exercise Pattern: Push-ups, pull ups, and ab workouts.
Sleep/rest
Sleep Pattern: Erratic; changes drastically
Naps: Not recently
Sleep Aids: N/A
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NURS 3308
Health History Template
Nutrition/Elimination
24-hour diet recall to include:
Breakfast- Oatmeal
Lunch- Macaroni, sausage
Dinner- Pizza
Snacks- Chips
Fluids- Coffee, water, tea
Voiding (usual pattern, times per day): 3-4 times per day
Bowel (usual pattern): Once a day
Interpersonal relationships/resources
Social Roles: Gets along well with family, feels safe
Support Systems: Mother, significant other, friends
Time Alone: Pleasurable time alone
Spiritual assessment (FICA)Faith: Describe your spirituality, faith or belief? NOTE: If patient says they are not religious, ask them
what gives their life meaning and/or purpose
Family gives patient’s life meaning and purpose.
Importance and Influence: Does it influence how you think about your health?
The patient states, “not really,”.
Community: Are you a part of a faith community/congregation and receive support from them?
No, patient is not a part of a faith community for support.
Address and Application: Do you have specific spiritual needs that need addressing?
Patient states that he needs to start meditating again.
Coping and stress management
Stresses: School, Financial Stressors
Stress Relief Measures: Exercise, meditation, yoga, talk to friends
Personal habits to include
Tobacco (PPD): N/A
Alcohol: N/A
Street drugs: N/A
Environment hazards
Housing/neighborhood: N/A
Workplace or Occupational Hazards: Driving Safety
Seat Belt Use: YES
Travel Outside of Country (where, when & how long): Never been outside of the country.
Intimate Partner Violence: Do you feel safe? Yes.
Have you ever been emotionally or physically abused by your partner or someone important to
you? No.
Occupational health: Healthy within workplace and school.
VIII. Patient’s Perception of Health: How do you define health? How do you view your situation now?
What are your concerns, or what are your health goals?
Patient states that health is the health and wellbeing of your body & mind; a balance of your biological,
spiritual, and mental needs to perform essential functions in daily life.
Patient believes he is healthy, despite current concern.
Patient’s health goals involve maintaining physical and mental health status, flexibility, getting fit,
starting cardio.
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NURS 3308
Health History Template
IX. Based on the assessment data you have collected in this health history, list three prioritized health
concerns you have for this patient:
1. Exacerbated issues in genital region.
2. Possible pain increase; need to monitor & reassess after treating chief complaint.
3. Parkinson’s history; take preventative precautions.
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