Nursing: History & Physical Assignment

• Typed, double spaced using Word (Office 2007 or 2010)
• Include your name on it
• Use headings as appropriate(see below) and format them uniformly throughout the paper.
• Use correct spellings and grammar; the majority of the assignment grade will be based on the content covered, but points will be deducted for misspellings and grammatical errors.
• Refer to the HIPAA rules listed in the syllabus for information to omit. If you have a question about including any piece of information, contact the course instructor.
• Submit the completed assignment as a file upload through the Canvas Assignments tool.

Supporting Materials

This is how the Running head should appear on page 1, it is different on all other pages – please review. Please remember the running head after the colon cannot be more than 50 characters, including spaces. Your title in the running head may be shortened due to this.

Adult Health History

First and Last Name

Indiana University Southeast

Adult Health History

This documentation is a comprehensive health history of TJ, a 45 year old male who lives

in Indiana. TJ has been married for 25 years. He and his wife have two daughters who are 21

and 22. The oldest daughter has a masters in elementary education and teaches in the Greater

Clark school corporation. She has been married for two years and she and her husband are

expecting their first child in May. The youngest daughter is finishing her senior year of nursing

school at the University of Louisville. TJ denied having any cultural, religious or spiritual values

that would inhibit him from participating in this interview. TJ denies any exposure to domestic

partner violence or sexual abuse. The interview took place in TJ’s living room. The setting was

very nice, quiet, comfortable, and free from distractions.

Present Health/History of Present Problem(s )

TJ reports no present health issues.

.

Past Health

Childhood illnesses

TJ denies having measles, mumps, or rubella (MMR ), and pertussis. He did report

having chicken pox at age six. Many episodes of strep throat (denies knowledge of rheumatic

fever), tonsillectomy at age nine.

Accidents or injuries

Bike wreck in third grade, broken collar bone and pulled growth center from humerous.

Laid in traction for three weeks at hospital. Doctor was not sure if damage to growth plate would

cause long term issues. Arm grew at normal rate and size, no problems.

Serious or chronic illnesses

Denies any history of serious or chronic illnesses.