Question Answered step-by-step Create an Example Health History Patient and Nurse Inteview of a Male Diabetic Patient. Fill up the form with the possible answers of a Diabetic Patient. Create your own answers. COMPREHENSIVE HEALTH HISTORY Date:_________________ DEMOGRAPHICName:____________________________ Age:____ Gender:__________________ Nationality:___________ Marital Status:______ Language spoken:______________ Occupation:_______________ HEALTH HISTORYProblems at birth:_______________________ Allergies (Food or Medications) State reactions:_________________________________________________Childhood Illnesses:_______________________________________________________Immunizations:___________________________________________________________Previous Illnesses: _________________________________________________________________________Previous Surgeries: ________________________________________________________________________Implanted medical devices (e.g. Pacemaker, Titanium implants):__________________________________Pregnancies: Total Birth: _____ Miscarriage:______ Abortions:____ Stillbirths:________________Accidents or Injuries:______________________________________________________________________Disability / Mobility problems:________________________ Assistive devices needed:__________________ Mental health concerns (e.g. stress, depression):_________________________________________________ MedicationsGeneric (Brand Name)Dosage and Frequency RouteLate dose taken FAMILY HEALTH HISTORYHereditary disordersRelationship to the patient SPECIFIC HEALTH HISTORY:SUBSTANCE USESubstanceQuantityStimulantsCoffee (specify brand)Energy drink (specify brand) Alcohol Wine (specify brand)Beer (specify brand)Hard Liquor (specify brand) Cigarette SmokingVape Recreational drugs / Prohibited drugs SOCIAL, EDUCATION, RELIGION AND RECREATIONAL Religion and Religious practices Educational Attainment Living accommodation (House, Apartment, Condominium) Living arrangement(With partner, family, alone, friends) HEALTH PROMOTION PRACTICES Sleep (On the average number of hours of sleep) Diet (Rate: Good, Fair, Poor) Activities: Sports and exercise (specify specific activity and duration) USE OF MEDICAL RESOURCES ServicesFrequency utilizedDoctor Dentists Other health professionals (specify if any and how frequent do you visit them):_______________________________________________________________________________ DIAGNOSTIC AND LABORATORY TEST Diagnostic and Laboratory Test done within the last 1 year.TestNormal / Abnormal resultsFindings SOURCES OF HEALTH INFORMATION Where do you get your Health formation (Select all that apply)?( ) Allied Health Professional (e.g. Physician, Nurse) Please specify:_____________________________( ) Website, Please specify:________________________________( ) TV Shows, Please specify:______________________________( ) Others (e.g Folk leaders, Social media), Please specify:_________________________ Health Science Science Nursing NURS 141 Share QuestionEmailCopy link Comments (0)
Question Answered step-by-step Create an Example Health History Patient and Nurse Inteview of a Male Diabetic Patient. Fill up the form with the possible answers of a Diabetic Patient. Create your own answers. COMPREHENSIVE HEALTH HISTORY Date:_________________ DEMOGRAPHICName:____________________________ Age:____ Gender:__________________ Nationality:___________ Marital Status:______ Language spoken:______________ Occupation:_______________ HEALTH HISTORYProblems at birth:_______________________ Allergies (Food or Medications) State reactions:_________________________________________________Childhood Illnesses:_______________________________________________________Immunizations:___________________________________________________________Previous Illnesses: _________________________________________________________________________Previous Surgeries: ________________________________________________________________________Implanted medical devices (e.g. Pacemaker, Titanium implants):__________________________________Pregnancies: Total Birth: _____ Miscarriage:______ Abortions:____ Stillbirths:________________Accidents or Injuries:______________________________________________________________________Disability / Mobility problems:________________________ Assistive devices needed:__________________ Mental health concerns (e.g. stress, depression):_________________________________________________ MedicationsGeneric (Brand Name)Dosage and Frequency RouteLate dose taken FAMILY HEALTH HISTORYHereditary disordersRelationship to the patient SPECIFIC HEALTH HISTORY:SUBSTANCE USESubstanceQuantityStimulantsCoffee (specify brand)Energy drink (specify brand) Alcohol Wine (specify brand)Beer (specify brand)Hard Liquor (specify brand) Cigarette SmokingVape Recreational drugs / Prohibited drugs SOCIAL, EDUCATION, RELIGION AND RECREATIONAL Religion and Religious practices Educational Attainment Living accommodation (House, Apartment, Condominium) Living arrangement(With partner, family, alone, friends) HEALTH PROMOTION PRACTICES Sleep (On the average number of hours of sleep) Diet (Rate: Good, Fair, Poor) Activities: Sports and exercise (specify specific activity and duration) USE OF MEDICAL RESOURCES ServicesFrequency utilizedDoctor Dentists Other health professionals (specify if any and how frequent do you visit them):_______________________________________________________________________________ DIAGNOSTIC AND LABORATORY TEST Diagnostic and Laboratory Test done within the last 1 year.TestNormal / Abnormal resultsFindings SOURCES OF HEALTH INFORMATION Where do you get your Health formation (Select all that apply)?( ) Allied Health Professional (e.g. Physician, Nurse) Please specify:_____________________________( ) Website, Please specify:________________________________( ) TV Shows, Please specify:______________________________( ) Others (e.g Folk leaders, Social media), Please specify:_________________________ Health Science Science Nursing NURS 141 Share QuestionEmailCopy link Comments (0)
