Type Of Service : Health Assessment

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Health History Thalia Braschi Chamberlain School of Nursing NR302-Health Assessment Part I September 2015 Service Date: 09/18/2015 Type of Service: Health Assessment (Annual) Patient Name: XV Biographic Data XV is a 47 year-old divorced Caucasian female. Born on Oct 6, 1968 in San Diego, California and currently resides in Alexandria, Virginia. Her ethnic origin is American. XV is employed full time for the Arlington County government. She is insured for medical, dental, and eye care through her employer. XV is catholic who states belief in alternative therapies. Source of information was obtained from the patient who seems to be reliable, alert, oriented, and recall of information intact. Present Health Status or Illness XV seeks healthcare for her annual health assessment. XV denies any concerns or health complaints at time of visit except for “occasional left sided headaches.” She states “I have no current medications other than a multivitamin everyday and 2 tablets of Excedrin migraine as needed.” XV believes “health is very important.” She added “for someone to be healthy there must be a balance between physical, mental and spiritual.” XV expresses being pro-active in obtaining her yearly routine physical, gynecologic, dental, and eye examinations. Past Health History XV is currently up to date on all immunizations such as but limited to: polio, rubella, Hepatitis B, influenza, tetanus, and varicella. Patient denies any major illnesses and prior

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