Health History and Physical

Complete a health history and physical examination of an individual. Using the following subjective and objective components and your textbook for explicit details about each category, complete an individual's health history and physical examination and fill in the template below. Make sure to use correct terminology while documenting the details of each section. The person interviewed must be 18 years of age or older. Please avoid using any identifiers in preparing the assignment and follow HIPAA protocols.


Assignment Sections and

Required Criteria


Assessment Documentation

Reference Citations (If needed)

Health History




Demographic data




Reason for care




Present illness (PQRST of current illness)




Perception of health




Past medical history (including medications, allergies, vaccinations, and immunizations)




Family medical history




Review of systems




Developmental considerations

(using Erikson’s Stages of

Psychosocial Development)




Cultural considerations




Psychosocial considerations




Presence or absence of collaborative resources





Physical Examination:

Objective Data




HEENT (head, eyes, ears, nose, and throat



Neck (includes thyroid and lymph chains)




Respiratory system




Cardiovascular




Neurological system




Gastrointestinal system




Musculoskeletal system




Peripheral vascular system




Needs Assessment




Based on the health history and physical examination findings, determine at least two health education needs for the individual. Remember, you may identify an educational topic that is focused on wellness.




Support the identified health teaching needs selected with evidence from two peer reviewed journal articles.




Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education.




Describe how the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) affect proposed teaching.






















Reflection

1.) Reflect on your interaction with the interviewee holistically.

a. Describe 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.


2.) How did your interaction compare to what you have learned?


3.) What barriers to communication did you experience?

a. How did you overcome them?

b. What will you do to overcome them in the future?


4.) What went well with this assignment?


5.) Were there unanticipated challenges during this assignment?


6.) Was there information you wished you had available but did not?


7.) How will you alter your approach next time?

References