Health Assessment

Date: ____1/25/2012______
Client Initials: FY

Student: _______________
Age: 81

Gender: F

Allergies:
Meds/ Food/ Environmental
None
Medications:
Name:
Hydrochlorot
Nitrofur Mac
Doxepin
Alprozolam
Extra Strength Tylenol

Dose:
25mg
50mg
75mg
.25mg
2 caplets

Reaction

Route/ Frequency:
o.p.d.
o.p.d.
h.s.
p.r.n.
p.r.n.

Reason Taking
High BP
UTI
Depression
Anxiety
Pain

Health History:
Present Illness/ Concerns:
Sensory/ Neurologic History:
Yes No
Yes No
___ _x__ Dizziness or fainting
___ _x__ Stroke
___ _x__ Hearing deficit- Right/Left
___ _x__ Vision problems- Right/Left
___ _x__ Hearing Aids- ______
_x__ ___ Eyeglasses
___ _x__ Surgeries/ other:
_____________________________________________________________________________________
Explain:
age related decline in vision

Cardiovascular (chest pain, heart attack, edema):

Yes No

Yes No

___ _x__ Circulation problems

___ _x__ Heart trouble or murmur
_x__ ___ High blood pressure
___ _x__ High cholesterol
___ _x__ Surgeries/ other:
______________________________________________________________________

Explain:
Presently taking 25mg of Hydrochlorot o.p.d. to control high BP

Respiratory:
Yes No

Yes No

___ _x__ Bronchitis,

___ _x__ Chronic lung disease
___ _x__ Pneumonia
___ _x__ Asthma
___ _x__ Surgery/ other:
_______________________________________________________________________

Explain:_______________________________________________________________________________
______________________________________________________________________________________

Gastrointestinal:
Yes No

Yes No

___ _x__ Acid Reflux disease

___ _x__ Irritable bowel syndrome
Bowel Pattern: ____o.p.d._____________________________

___ _x__ Surgery: ____________________

Explain:_______________________________________________________________________________
______________________________________________________________________________________

Genitourinary/Gyn:
Yes No

Yes No

_x__ ___ Kidney or bladder trouble, difficulty urinating

___ _x__ ovarian/gyn problem
___ _x__ Surgery: ___________________________________________________________________________

Explain:
Had problems with UTIs in past, has been on 25mg of Nitrofur Mac o.p.d. for the past year and a half and
has not had a UTI since being on medication.

Endocrine:
Yes No
___ _x__ Diabetes ( ____ Diet-controlled;
___ _x__ Thyroid problems
________________________

Yes No
____ Insulin)

___ _x__ Breast Cancer

___ _x__ Surgery:

Explain:_______________________________________________________________________________
______________________________________________________________________________________

Musculoskeletal (arthritis, fractures, joint injuries):

Yes No

Yes No

___ _x__ Arthritis/ location:_________________________

_x__ ___ Fracture/ location:_________________________
___ ___ Surgery/ other: ________________________

___ _x__ Osteoporosis

_x__ ___ Back pain

Explain:
Had left hip replacement in 1996 and a repeat surgery on same side in 1998. Goes to therapy 2x week,
experiences lower back pain occasionally.

Integument/ Skin Problems:

Yes No
Yes No
___ _x__ Itchy, dry skin
___ _x__ Rashes
___ _x__ Other skin problem
Explain:_______________________________________________________________________________

Personal/Social History:
Diet: Regular
Tobacco Use: never
Did you get an Influenza Vaccine this year? Yes
Date of last Pneumovax: unknown
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Exercise: 3x week
Alcohol Use: never

Review of Systems:
T-P-R: n/a, 72, 14
General Appearance:

BP: 144/86

Pulse Ox: 95

Blood Glucose: 101

Overall a well developed, healthy, elderly white woman sitting up in chair, no difficulty breathing, good,
even skin color.

1. Neurological/ Mental Status:

LOC/ orientation (A&Ox3): A&Ox3
Memory (recent, remote):
Pupils (PERRLA, cardinal fields): good, wears eyeglasses
Speech (clear, appropriate, slurred): clear
Sensation (check 4 extremities): sensation in all 4 extremities
2. Cardiovascular:
Chest pain, SOB on exertion:
Peripheral pulses palpable (radials, DPs):
Apical pulse rate: 66
Capillary refill: normal 1-2sec refill
Edema: no signs of edema
3. Respiratory:
Breath Sounds (clear, crackles, gurgles, wheeze): clear
Cough/sputum: none
Oxygen use: no
4. Gastrointestinal:
Oral exam (teeth, dentures): partial upper plate denture, gums & tongue pink
Auscultation (BSx4 quads): normal BS
Palpation (tenderness/location): no tenderness
5. Musculoskeletal:
ROM x 4 extremities: full ROM x 4
Muscle Strength x 4 extremities: good x 4
Assistive devices (walker, cane): Uses cane occasionally when going out for long periods of time
Cast, splints, brace, etc.: none
6. Integument:
Itching, burning, irritation: none
Color: normal
Turgor: hydrated
Rashes, bruises (location): none
Wound/s (location, description): none

Psychosocial Assessment:
Where were you born? _____Mifflintown, PA__________________________________
Tell me about your mother and father- their jobs, where did you live, etc.
___Mother was a school teacher until she had children, from that point on she was a stay at home mother
until she passed away at age 46 of cancer. Father was a farmer and died at the age of 88 from
cancer.________________________________________________________________________________

# Of older brothers__0__ / sisters _2___

# of younger brothers__0__ / sisters __0___

Where are your brothers and sisters now? ___Oldest sister lives nearby and will be 90 in August
and other sister is 88 and is in the latter stages of Alzheimers. _____________________________
Where did you go to school/ level of education? ___One room school, then Jersey Shore High
School.__________________________________________________________________
What types of jobs have you had? ___Fostered infants for several years, followed by working as a
nursing assistant in a geriatric facility.______________________________________________
Did you like your work? ___Enjoyed very much._________________________________________
____________________________________________________________________________
Are you/ were you married? ___ If yes, # of years: _59_ Divorced: ___ Widowed: _x___
Do you have children? ____3_____ If yes,

# girls___2___

# boys___1____

Where are your children now? ___Oldest daughter lives on Lafayette Pkwy. Other daughter lives in
Marietta, PA and son lives in Woodbury, PA__________________________________________
How is your relationship with them? ____Good. Son works long hours, so does not see very
often._________________________________________________________________________________

# Of grandchildren ___8___ # Of great-grandchildren ___6___

Who are the other significant persons in your life? ____Other residents in home and church
friends.____________________________________________________________
Do you drive? _No__ If not, method of transportation: __STEP or daughter_______________
_______________________________________________________________________
Do you have any hobbies/ community activities? __Bible study_____________________
_______________________________________________________________________
_
What would you say is the biggest challenge in your life? __Waiting to get out of this life and
onto the next.______________________________________________________________
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