Define Self-Care

In: Science

Submitted By kec001
Words 903
Pages 4
Comprehensive Health History Interview

NAME

University of North Carolina at Pembroke

Abstract

T.J. was the patient for a comprehensive health history interview. Patient was a reliable source to answer questions and was able to recall information from recent and distant past events that were needed to complete the health history. T.J. recalled childhood illnesses and immunizations, and patient’s family history was obtained. The review of systems was discussed and documented, as well as the functional assessment. Nursing diagnoses deemed appropriate were applied for the client. A blended format of the traditional systems approach and the functional health patterns were used.

Comprehensive Health History Interview
Biographical Data
Name: Karen Carlisle
Address: 205 nottingham lane
Red Springs nc 28377
Phone Number: 910-734-6143
Date of Birth: 06-15-72
Current Age: 43
Gender: f
Race: c
Ethnic Origin: Baptist
Marital Status: Single
Occupation: RN
Education: BSN
Contact Person: Frances Carlisle
Source of History
T.J. was the source of history. Client was reliable and oriented x3. She was able to verbalize information needed to obtain the health history.
Reason for Seeking Healthcare
“To help with final check-off.” (T.J., personal communication, April 29th, 2014).
Present History
States she is in a good state of health. Denies any health concerns. Denies any current medical conditions such as anemia, arthritis, depression, heart problems, thyroid disease, seizures, or diabetes.
Past Health
Childhood Illnesses: States she had chicken pox between the ages of 5 and 6. Accidents/Injuries: Face busted playing softball 2002
Hospitalizations: States routine 48-hour hospitalization when delivery her child. Denies any other hospitalizations.
Operations: Denies any operations.
Immunizations: States having received MMR, tetanus and Hepatitis…...

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