Health History Worksheet This worksheet is used to assist the student in gathering and organizing information when conducting a health history.
Family Member Description Paternal grandfather
First and last initials: L. M. Birthdate: April 11 1916 Death date: April 1984 Occupation: Private business man Education: some college Primary language: English Health summary: passed from lymphoma and lung cancer
Paternal grandmother First and last initials: C. M. Birthdate: May 20 1919 Death date: December 1980 Occupation: House wife Education: high school Primary language: English Health summary: passed from aneurism
Father First and last initials: W. M. Birthdate: October 25 1959 Death date: Alive Occupation: Failure Analysis Engineer at NASA Education: Bachelors from Mississippi State Primary language: English Health summary: Severe neck Arthritis
Father’s siblings- Summary of any significant health issues
One sibling with cancer, one sibling with fibromyalgia
Maternal grandfather First and last initials: Unknown Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Maternal grandmother First and last initials: E. V. Birthdate: June 1940 Death date: August 1978 Occupation: House wife Education: none Primary language: Spanish Health summary: passed from Stomach cancer
Mother First and last initials: R. V. M. Birthdate: July 1 1961 Death date: Alive Occupation: house wife Education: Some high school Primary language: Spanish Health summary: No health conditions
Mother’s siblings- Summary of any significant health issues No health conditions Adult Participant
First and last initials: B.M. Birthdate: July 27 1998 Death date: Alive Occupation: Student Education: College Primary language: English Health summary: No serious health conditions
Adult participant’s siblings Summary of any significant health issues None Adult participant’s spouse/significant other
First and last initials: N/A Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Adult participant’s children- Up to 4 children N/A Child #1 first and last initials:
Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Child #2 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Child #3 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Child #4 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Family Member Description Paternal grandfather
First and last initials: L. M. Birthdate: April 11 1916 Death date: April 1984 Occupation: Private business man Education: some college Primary language: English Health summary: passed from lymphoma and lung cancer
Paternal grandmother First and last initials: C. M. Birthdate: May 20 1919 Death date: December 1980 Occupation: House wife Education: high school Primary language: English Health summary: passed from aneurism
Father First and last initials: W. M. Birthdate: October 25 1959 Death date: Alive Occupation: Failure Analysis Engineer at NASA Education: Bachelors from Mississippi State Primary language: English Health summary: Severe neck Arthritis
Father’s siblings- Summary of any significant health issues
One sibling with cancer, one sibling with fibromyalgia
Maternal grandfather First and last initials: Unknown Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Maternal grandmother First and last initials: E. V. Birthdate: June 1940 Death date: August 1978 Occupation: House wife Education: none Primary language: Spanish Health summary: passed from Stomach cancer
Mother First and last initials: R. V. M. Birthdate: July 1 1961 Death date: Alive Occupation: house wife Education: Some high school Primary language: Spanish Health summary: No health conditions
Mother’s siblings- Summary of any significant health issues No health conditions Adult Participant
First and last initials: B.M. Birthdate: July 27 1998 Death date: Alive Occupation: Student Education: College Primary language: English Health summary: No serious health conditions
Adult participant’s siblings Summary of any significant health issues None Adult participant’s spouse/significant other
First and last initials: N/A Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Adult participant’s children- Up to 4 children N/A Child #1 first and last initials:
Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Child #2 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Child #3 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Child #4 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Family Member Description Paternal grandfather
First and last initials: L. M. Birthdate: April 11 1916 Death date: April 1984 Occupation: Private business man Education: some college Primary language: English Health summary: passed from lymphoma and lung cancer
Paternal grandmother First and last initials: C. M. Birthdate: May 20 1919 Death date: December 1980 Occupation: House wife Education: high school Primary language: English Health summary: passed from aneurism
Father First and last initials: W. M. Birthdate: October 25 1959 Death date: Alive Occupation: Failure Analysis Engineer at NASA Education: Bachelors from Mississippi State Primary language: English Health summary: Severe neck Arthritis
Father’s siblings- Summary of any significant health issues
One sibling with cancer, one sibling with fibromyalgia
Maternal grandfather First and last initials: Unknown Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Maternal grandmother First and last initials: E. V. Birthdate: June 1940 Death date: August 1978 Occupation: House wife Education: none Primary language: Spanish Health summary: passed from Stomach cancer
Mother First and last initials: R. V. M. Birthdate: July 1 1961 Death date: Alive Occupation: house wife Education: Some high school Primary language: Spanish Health summary: No health conditions
Mother’s siblings- Summary of any significant health issues No health conditions Adult Participant
First and last initials: B.M. Birthdate: July 27 1998 Death date: Alive Occupation: Student Education: College Primary language: English Health summary: No serious health conditions
Adult participant’s siblings Summary of any significant health issues None Adult participant’s spouse/significant other
First and last initials: N/A Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Adult participant’s children- Up to 4 children N/A Child #1 first and last initials:
Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Child #2 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Child #3 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:
Child #4 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:
An example Family Member Description Paternal grandfather
First and last initials: RL
Birthdate: 1921 Death date: 1981 Occupation: Retired as a coal miner Education: 6th grade Primary language: English
Health summary: He was diagnosed with chronic lung disease, diabetes, and hypertension. He died from a heart attack.
Paternal grandmother First and last initials: ML
Birthdate: 1932 Death date: 1998 Occupation: House wife Education: Does not want to disclose Primary language: English
Health summary: Diagnosed with chronic lung disease from smoking cigarettes. Died from heart failure.
This example points to common problems among this generation on both sides of the Adult Participant’s family. Consider the potential implications this would have for the Adult Participant’s health status.
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Original Date:
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Dates Revised:
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enter text.
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enter text.
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enter text.
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enter text.
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HEALTH HISTORY QUESTIONNAIRE
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All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
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Initials:
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Race/Ethnicity:
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☐M ☒
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Age
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Occupation: Student
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Marital status:
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☒ Single ☐ Partnered ☐ Married ☐ Separated ☐ Divorced ☐ Widowed
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Reason for visit: Physical assessment
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Perception of health:enter text.
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Date of last physical exam:
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8/22/2018
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Source of information: enter text.
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Reason for seeking care: Physical Assessment
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Present health or history of present illness:
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P
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enter text.
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Q
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enter text.
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R
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enter text.
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S
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enter text.
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T
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enter text.
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PERSONAL HEALTH HISTORY/Past health
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Childhood illness:
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◻ Measles ◻ Mumps ◻ Rubella ◻ Chickenpox ◻ Rheumatic Fever ◻ Polio
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Immunizations and dates:
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☒Tetanus
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Up to date
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☒Pneumonia
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Up to date
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☒Hepatitis
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Up to date
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☒Chickenpox
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Up to date
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☒Influenza
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Up to date
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☒MMR Measles, Mumps, Rubella
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Up to date
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List any medical problems that other doctors have diagnosed
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N/A
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Surgeries
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Year
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Reason
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Hospital
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N/A
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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Other hospitalizations
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Year
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Reason
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Hospital
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N/A
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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Have you ever had a blood transfusion?
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☐
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Yes
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☒
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No
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Please turn to next page
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List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
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Name the Drug
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Strength
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Frequency Taken and Reason
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Claritin
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enter text.
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1 or 3 times per week
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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Allergies to medications, latex, food, iodine/betadine
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Name the Drug
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Reaction You Had
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N/A
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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HEALTH HABITS AND PERSONAL SAFETY
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All questions contained in this questionnaire are optional and will be kept strictly confidential.
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Exercise
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☐Sedentary (No exercise)
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☐Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
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☐Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
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☒Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
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Diet
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Are you dieting?
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☐
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Yes
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☒
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No
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If yes, are you on a physician prescribed medical diet?
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☐
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Yes
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☐
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No
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# of meals you eat in an average day? Click or tap here to enter text.
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Rank salt intake
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☐Hi
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☐Med
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enter text.Low
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Rank fat intake
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☐Hi
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☐Med
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enter text.Low
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Caffeine
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◻ None
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☒Coffee
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☐Tea
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Coke Cola
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# of cups/cans per day? 1 cup/day
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Alcohol
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Do you drink alcohol?
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☒
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Yes
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☐
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No
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If yes, what kind? Beer
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How many drinks per week? 1 per week
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Are you concerned about the amount you drink?
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☐
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Yes
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☒
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No
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Have you considered stopping?
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☐
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Yes
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☒
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No
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Have you ever experienced blackouts?
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☐
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Yes
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☒
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No
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Are you prone to “binge” drinking?
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☐
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Yes
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☒
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No
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Do you drive after drinking?
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☐
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Yes
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☒
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No
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Tobacco
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Do you use tobacco?
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☐
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Yes
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☒
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No
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☐Cigarettes – pks./day enter text.o
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☐Chew - #/day enter text.
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☐Pipe - #/day enter text.
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☐Cigars - #/day enter text.
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☐ # of years enter text.
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☐Or year quit enter text.
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Drugs
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Do you currently use recreational or street drugs?
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☐
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Yes
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☒
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No
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Have you ever given yourself street drugs with a needle?
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☐
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Yes
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☒
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No
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Sex
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Are you sexually active?
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☒
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Yes
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☐
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No
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If yes, are you trying for a pregnancy?
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☐
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Yes
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☒
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No
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If not trying for a pregnancy list contraceptive or barrier method used: birth control
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Any discomfort with intercourse?
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☐
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Yes
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☒
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No
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Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?
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☐
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Yes
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☒
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No
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Personal Safety
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Do you live alone?
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☐
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Yes
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☒
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No
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Do you have frequent falls?
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☐
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Yes
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☒
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No
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Do you have vision or hearing loss?
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☒
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Yes
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☐
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No
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Do you have an Advance Directive and/or Living Will?
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☐
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Yes
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☒
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No
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Would you like information on the preparation of these?
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☐
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Yes
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☒
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No
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Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?
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☐
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Yes
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☒
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No
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FAMILY HEALTH HISTORY
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Age
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Significant Health Problems
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Age
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Significant Health Problems
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Father
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60
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Arthritis
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Children
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☐M ☐ F
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N/A
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Mother
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56
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N/A
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☐M ☐ F
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N/A
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Sibling
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☒M 23 years old ☐ F
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N/A
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☐M ☐ F
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N/A
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☐M ☐ F
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N/A
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☐M ☐ F
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N/A
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☐M ☐ F
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N/A
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Grandmother Maternal
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passed from Stomach cancer in 1978
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☐M ☐ F
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N/A
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Grandfather Maternal
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enter text.
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unknown
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☐ M ☐ F
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N/A
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Grandmother Paternal
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enter text.
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passed from aneurysm in 1980
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☐M ☐ F
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N/A
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Grandfather Paternal
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enter text.
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passed from lymphoma and lung cancer in 1984
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MENTAL HEALTH
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Comments
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Is stress a major problem for you?
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☐
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Yes
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☐
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No
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Do you feel depressed?
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☐
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Yes
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☐
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No
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Do you panic when stressed?
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☐
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Yes
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☐
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No
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Do you have problems with eating or your appetite?
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☐
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Yes
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☐
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No
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Do you cry frequently?
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☐
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Yes
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☐
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No
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Have you ever attempted suicide?
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☐
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Yes
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☐
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No
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Have you ever seriously thought about hurting yourself?
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☐
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Yes
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☐
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No
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Do you have trouble sleeping?
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☐
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Yes
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☐
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No
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Have you ever been to a counselor?
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☐
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Yes
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☐
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No
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WOMEN ONLY
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Age at onset of menstruation: 12.
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Date of last menstruation: May 15, 2019
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Period every 28 days
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Heavy periods, irregularity, spotting, pain, or discharge?
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☐
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Yes
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☐
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No
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Number of pregnancies enter text. Number of live births enter text.
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Are you pregnant or breastfeeding?
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☐
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Yes
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☐
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No
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Have you had a D&C, hysterectomy, or Cesarean?
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☐
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Yes
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☐
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No
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Any urinary tract, bladder, or kidney infections within the last year? UTI
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☐
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Yes
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☐
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No
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Any blood in your urine?
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☐
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Yes
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☐
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No
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Any problems with control of urination?
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☐
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Yes
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☐
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No
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Any hot flashes or sweating at night?
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☐
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Yes
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☐
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No
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Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?
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☐
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Yes
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☐
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No
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Experienced any recent breast tenderness, lumps, or nipple discharge?
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☐
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Yes
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☐
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No
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Date of last pap and rectal exam? 2017.
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MEN ONLY
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Do you usually get up to urinate during the night?
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☐
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Yes
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☐
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No
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If yes, # of times enter text.
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Do you feel pain or burning with urination?
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☐
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Yes
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☐
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No
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Any blood in your urine?
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☐
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Yes
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☐
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No
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Do you feel burning discharge from penis?
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☐
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Yes
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☐
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No
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Has the force of your urination decreased?
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☐
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Yes
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☐
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No
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Have you had any kidney, bladder, or prostate infections within the last 12 months?
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☐
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Yes
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☐
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No
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Do you have any problems emptying your bladder completely?
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☐
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Yes
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☐
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No
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Any difficulty with erection or ejaculation?
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☐
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Yes
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☐
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No
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Any testicle pain or swelling?
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☐
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Yes
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☐
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No
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Date of last prostate and rectal exam? enter text.
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review of systems
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Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
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☐
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Skin/Hair/Nails enter text.
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☐
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Respiratory enter text.
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☐
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Neurologic enter text.
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☐
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Head/Neck enter text.
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☐
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Cardiovascular enter text.
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☐
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Recent changes in Weight enter text.
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☐
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Eyes Bilateral Myopia and Astigmstism
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☐
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Peripheral Vascular enter text.
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☐
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Recent changes in Energy level enter text.
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☐
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Ears enter text.
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☐
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Gastrointestinal enter text.
|
☐
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Sleep/rest pattern enter text.
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☐
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Nose enter text.
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☐
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Urinary UTI
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☐
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Other pain/discomfort: enter text.
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☐
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Mouth/Throat enter text.
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☐
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Musculoskeletal enter text.
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1
NR302 Health Assessment I
RUA: Health History Guidelines
NR302 Health History Guidelines V3.docx Revised: 04/2019
11
Purpose Before any nursing plan of care or intervention can be implemented or evaluated, the nurse assesses the individual through the collection of both subjective and objective data. The data collected are used to determine areas of need or problems to be addressed by the nursing care plan. This assignment will focus on collecting subjective assessment data, synthesizing the data, and on identifying health/wellness priorities based on the findings. The purpose of the assignment is two-fold:
To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual, and
developmental) affecting health and wellness.
To reflect on the interactive process between self and client when conducting a health assessment.
Course Outcomes: This assignment enables the student to meet the following course outcomes:
CO1. Explain expected client behaviors while differentiating between normal findings, variations, and abnormalities. (PO1)
CO2. Utilize prior knowledge of theories and principles of nursing and related disciplines to integrate clinical judgment in professional decision-making and implementation of nursing process while obtaining a physical assessment. (PO 4, 8)
CO3. Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1)
CO4. Utilize effective communication when performing a health assessment. (PO 3) CO6. Identify teaching/learning needs from the health history of an individual. (PO 2, 3) CO7. Explore the professional responsibilities involved in conducting a comprehensive health assessment and
providing appropriate documentation. (PO 6, 7)
Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment.
Total points possible: 100 points
Preparing the assignment A Health History Worksheet that can be used to help you organize the Family Medical History information you will obtain from the Adult Participant is located in the Resources section of the Expand page for Unit 2. The use of this tool is optional. There are three parts to this assignment.
1. Health History Assessment (50 points/50%)
Using the following components of a health history assessment and your textbook for explicit details about each category, complete a health assessment/history on an individual of your choice. The person interviewed must be 18 years of age or older and should NOT be a family member or close friend. The purpose of this restriction is to avoid any tendency to anticipate answers or to influence how the questions are answered. Your goal in choosing an interviewee is to simulate the interaction between you and an individual for whom you would provide care. It is important that you inform the person of your assignment and assure him/her that the information obtained will be kept confidential. Please be sure to avoid the use of any identifiers in preparing the assignment. Health History components to be included:
a) Demographics b) Perception of Health c) Past Medical History d) Family Medical History
2
NR302 Health Assessment I
RUA: Health History Guidelines
NR302 Health History Guidelines V3.docx Revised: 04/2019
21
e) Review of Systems f) Developmental Considerations g) Cultural Considerations h) Psychosocial Considerations i) Collaborative Resources
2. Reflection (40 points/40%) Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Provide a written reflection that describes your experience with conducting this Health History.
a) Reflect on your interaction with the interviewee holistically.
I. Consider the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process (if needed, refer to your text for a description of therapeutic communication and of the interview process).
b) How did your interaction compare to what you have learned?
c) What went well?
d) What barriers to communication did you experience?
I. How did you overcome them?
II. What will you do to overcome them in the future?
e) Were there unanticipated challenges to the interview?
f) Was there information you wished you had obtained?
g) How will you alter your approach next time?
3. Style and Organization (10 Points/10%) Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired information, and appropriate writing skills. Scoring of your work in written communication is based on proper use of grammar, spelling and how clearly you express your thoughts and reasoning in your writing.
• Grammar and mechanics are free of errors. • Able to verbalize thoughts and reasoning clearly • Use appropriate resources and ideas to support topic
For writing assistance (APA, formatting, or grammar) visit the Citation and Writing Assistance: Writing Papers at CU page in the online library.
NR302 Health Assessment I
RUA: Health History Guidelines
NR302 Health History Guidelines V3.docx Revised: 04/2019
31
Grading Rubric Criteria are met when the student’s application of knowledge within the paper demonstrates achievement of the outcomes for this assignment.
Assignment Section and Required Criteria
(Points possible/% of total points available)
Highest Level of Performance
High Level of Performance
Satisfactory Level of
Performance
Unsatisfactory Level of
Performance
Section not present in
paper
Introduction of Disease (50 points/50%)
50 points 46 points 41 points 25 points 0 points
Required criteria 1. Demographics 2. Perception of Health 3. Past Medical History 4. Family Medical History 5. Review of Systems 6. Developmental Considerations 7. Cultural Considerations 8. Psychosocial Considerations 9. Collaborative Resources
Includes no fewer than 9 requirements for section.
Includes no fewer than 8 requirements for section.
Includes no less than 7 requirement for section.
Present, yet includes no required criteria.
No requirements for this section presented.
Reflection (40 points/40%)
40 points 36 points 33 points 20 points 0 points
Required criteria 1. Reflect on your interaction with the
interviewee holistically. a) Consider the interaction in its entirety:
include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process (if needed, refer to your text for a description of therapeutic communication and of the interview process).
b) How did your interaction compare to what you have learned?
Includes no fewer than 7 requirements for section.
Includes no fewer than 6 requirements for section.
Includes no fewer than 5 requirements for section.
Includes 4 or fewer requirements for section.
No requirements for this section presented.
NR302 Health Assessment I
RUA: Health History Guidelines
NR302 Health History Guidelines V3.docx Revised: 04/2019
41
Assignment Section and Required Criteria
(Points possible/% of total points available)
Highest Level of Performance
High Level of Performance
Satisfactory Level of
Performance
Unsatisfactory Level of
Performance
Section not present in
paper
c) What went well? d) What barriers to communication did you
experience? I. How did you overcome them?
II. What will you do to overcome them in
the future?
e) Were there unanticipated challenges to the
interview?
f) Was there information you wished you had
obtained?
g) How will you alter your approach next
time?
Style and Organization (10 points/10%)
10 points 8 points 4 points 0 points
Required criteria
1. Grammar and mechanics are free of errors.
2. Able to verbalize thoughts and reasoning clearly 3. Use appropriate resources and ideas to support
topic
Includes no fewer than 3 requirements for section.
Includes no fewer than 2 requirements for section.
Includes 1 requirements for section.
No requirements for this section presented.
Total Points Possible = 100 points

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