Health-Status Report Sample

Mental health: Client reported that he is currently waiting for an appointment for MH services from his OTP. The client reported his intention to continue attending a PTSD support group while in the program. Client denied having any S/I and H/I at this time.

Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). Example: During her interview Helen said, “…I can stay up all night having a good time. I don’t sleep or eat or slow down. I just keep on going for a week, maybe two.

Discuss the strengths and weaknesses of DSM-IV TR, as well as new changes for DSM-V.

PO had no service plan open in this dimension due to participating only one week in treatment. PO reported that he is living with his fiancé and her children at this time. PO reported he is not working due to working increased a level of stress and anxiety into his daily life. PO reported attending AA meeting and communicating with his sponsor regularly. PO will benefit from building and utilizing positive

DAS is recommended for this group as it is reliable and gives correct prediction and outcomes regarding depression. This assessment tool is easy to use; it is a self-report scale consisting of 40 items with each item having a statement and 7-point Likert scale. The questions used in this assessment are direct and easy making it efficient for most individuals' use (de Graaf, Roelofs, & Huibers, 2009). Besides,

During this quarter, Servando did not experience any acute episodes of illness, injuries, ER visits or Hospitalizations. He had a dental follow up on 07/18/16 which indicated Fair OH; no additional supports needed on this area. Annual hearing test was completed with normal hearing as per ENT. Client continues on LTBI treatment; monthly liver monitoring has been within normal. He received his seasonal Influenza vaccine 0.5 ml IM on 09/20/16.

History of Present Illness: The patient has been seen in this clinic since 2016. She is diagnosed to have ADHD, Bipolar II disorder, Generalized Anxiety disorder, Alcohol and Cannabis use dependence. The patient has struggled with separation from an abusive ex-husband, who is currently

There are many places to get information about treatment for alcohol dependency. There are programs to help cure this disease and get help. Some examples are as follows. One is Al-Anon/Alateen. This program helps families and friends of alcoholics deal with and recover from the effects of living with an alcoholism. Another is the National Drug and Treatment Referral Routing Service. This program provides treatment referral and information about treatment facilities. Lastly, there is the National Clearinghouse for alcohol and Drug Information. It provides information about alcohol and other

The purpose of this paper is to discuss the results of a comprehensive health assessment on a patient of my choosing. This comprehensive assessment included the patient 's complete health history and a head-to-toe physical examination. The complete health history information was obtained by interviewing the patient, who was considered to be a reliable source. Other sources of data, such as medical records, were not available at the time of the interview. Physical examination data was obtained

The main components of treatment include confrontation, detoxification, and rehabilitation (Friedlander & Norman, 2006). Confrontation involves overcoming patients’ denial, convincing them of the consequences of continued drinking, and motivating them to receive treatment (Friedlander & Norman, 2006). Detoxification consists of removing alcohol from the body and protecting the patient from the effects of withdrawal (Friedlander & Norman, 2006). Rehabilitation consists of continued efforts to increase and maintain high

Mr Johan experiences symptoms of panic attack when he feels self-conscious in front of other people when performing certain tasks. He reported feeling faint and had black out of thoughts during those episodes, whereby he was not able to think of anything. Both his hands would tremble and become numb. He would also be sweating but experienced no symptoms of pounding heart or choking

Teen and adults up to 35 - violent death from unintentional injury, homicide and suicide

The patient was born in Lagos, Nigeria. He migrated into the United States six years ago, October, 2009 through family ties. His highest education is high

What do the effects of sleep deprivation have on people? When a person does not get enough sleep, he or she is depriving his or her body of something that it needs. A delightful sleep is one of the most satisfying human experiences with a role to play in supporting a good mood and cognitive acuity as well as in promoting physiologic balance and resilience (Chittora, Jain and Suhalka). People think because they get an insufficient number of hours of sleep, they will not have an emotional impact by it. Sleep is a required need for peoples’ day to day life to be able to perform and stay healthy emotionally and physically. The effects of sleep deprivation are an issue because it affects mood, performance, and health.

Throughout this complete health assessment, I will approach my patient, a 49 years old, female, married patient, and perform a head to toe examination. Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings. This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that