Health History for Health Assessment Essay

Words: 3953
Pages: 16

NSG306 Health Assessment:
Health History on Mr. Ricky Ricardo
Jean Bors-Koefoed & Sarah Wright
Baptist College of Health Sciences

Health History
Biographical Data
Date: 05-23-2010
Name: Ricky Ricardo
Gender: Male
Race/Ethnicity: Hispanic
Marital Status: Married
Date of Birth: XX/XX/XX
Occupation: Medical Device Representative
Address: XXX XXXX
XXXXXXXXXXXXXXX
Phone Number: (XXX) XXX-XXXX
Contact Person (relationship to patient): Lucille Ball/wife (XXX) XXX-XXXX
Reason for Seeking Healthcare:
“Providing a Health History for Health Assessment”

History of Present Illness:
Patient does not have a present illness. He is only seeking care for the purpose of providing a health
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He received the Hepatitis B series between September and December of 1996. Because the patient currently works in hospital settings, he also had a titer done for all of the above diseases as further certification that he was indeed vaccinated on February 1, 2010.
Current problems can be explained by a patient’s immunization history, or by their lack of immunizations. It is important to have them updated if patient hasn’t received all or if they are just needing a tetanus shot. They help prevent diseases that are harmful if not life threatening. The patient is up to date on all common immunizations, with the exception of the varicella-zoster boosters, which was not routinely given when the patient was younger. Since he has had chickenpox in the past, he is considered to have the necessary immunity to the disease.
Last Examination: The patient’s last physical was Dec. 2007. Patient had elevated blood pressure (hypertension) due to stress. It was resolved on the follow-up visit on Feb. 2008. The patient’s last vision exam was Aug. 1997. The patient had 20/20 vision according to his last visit. His last dental exam was Feb. 2010. The patient has perfect teeth, and no cavities.
Yearly examinations are very important. It keeps the person having the exam and the physician up-to-date with their health status. They also detect early onset of certain diseases. While this patient