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Course Project Milestone 1:Health History
Guidelines and Grading Rubric
Purpose
The student will obtain a health history on
a willing, nonrelated, adult participant in order to generate written
documentation that is clear and accurate.Note: Failing to complete this assignment using an
adult participant other than yourself will result in a 20% penalty deduction
being applied.
Course Outcomes
This assignment enables the student to meet
the following Course Outcomes.
CO #3: Utilize
effective communication when performing a health assessment. (PO #3)
CO #4: Identify
teaching/learning needs from the health history of an individual. (PO #2)
CO #5: Explore
the professional responsibilities involved in conducting a comprehensive health
assessment and providing appropriate documentation. (PO #6)
Points
This assignment is worth a total of 200
points.
Due Date
The Course Project Milestone 1: Health
History assignment is to be submitted to the Dropbox by Sunday, 11:59 p.m. MT
at the end of Week 4. The guidelines and grading rubric may be found in Course
Resources. Post questions to the Q&A Forum. Contact your instructor if you
need additional assistance.
Disclaimer
The focus of this assignment is on
communicating details within the written client record. When taking a health
history on an actual client, it is essential that the information is accurate.
Please inform the person you are interviewing that they do not need to disclose
information that they wish to keep confidential. If the interviewee decides not
to share information, please write, “Does not want to disclose.”If the client
fails to disclose answers to several items, you will need to find another
client who is willing to share.
Directions
1.
Find an adult who is not related to you who is willing to let you take a
health history.
2. Download the NR305_Milestone1_Form
from Course Resources. You will type your answers directly into this Word
document. Your paper does not need to follow APA formatting; however, you are
expected to be clear in your communication by using correct medical
terminology, grammar, and spelling.
3.
Review the examples in Chapter 4 of your textbook to gain insight into
how to document the health history.Remember this is a health history, not a physical examination.Avoid words
like frequently, improved, increased, decreased, good, poor, normal, or WNL as
they may have different meanings for different people. Instead, document the
specific data that led you to these conclusions, for example, 3x/day instead of
frequently, or consuming four servings of vegetables/day instead of increased
vegetable servings.
4.
Save the file by clicking Save as and adding your last name to the file
name, for example, NR305_Milestone1_Form_Smith.
5.
Submit the completed form to the Dropbox by Sunday, 11:59 p.m. MT at the
end of Week 4.
6.
Please post questions in the weekly Q&A Forumsso the entire class
may view the answers.Course Project Milestone #1: Health History FormYour Name: Date:
Your Instructor’s Name: Directions: Refer to the Milestone 1: Health History guidelines and grading rubric
found in Course Resources to complete the information below.
This assignment is worth 200 points, with 10 points awarded for clarity of
writing, which means the use of proper grammar, spelling, and medical language.Type your answers
on this form. Click Save as and save the file with the assignment name and your
last name, for example, NR305_Milestone1_Form_Smith. When you are finished,
submit the form to the Milestone #1 Dropbox by the deadline indicated in your
guidelines. Post questions in the Q&A Forum or contact your instructor if
you have questions about this assignment.Disclaimer:The focus of this assignment is on communicating
details within the written client record. When taking a health history on an
actual client, it is essential that the information is accurate. Please inform
the person you are interviewing that they do not need to disclose information
that they wish to keep confidential. If the interviewee decides not to share
information, please write, “Does not want to disclose.”If
the client fails to disclose answers to several items, you will need to find
another client who is willing to share.Note: Failing to complete this assignment using an
adult participant other than yourself will result in a 20% penalty deduction
being applied.

BIOGRAPHICAL DATA (10 points)

Date:

Initials:

Age:

Date of birth:

Birthplace:

Gender:

Marital status:

Race:

Religion:

Occupation:

Health insurance:

Source of
information:

Reliability of
source of information:

PRESENT HEALTH HISTORY/ILLNESS (20 points)

Reason for
seeking care:

Health patterns:

Health goals:

HEALTH BELIEFS AND PRACTICES (15 points)

Beliefs and
practices:

Factors
influencing healthcare decisions:

Related traits,
habits or acts:

MEDICATIONS (20 points) (Please refer to
your assignment guidelines.)

Prescription
medications:

Over-the-counter
medications:

Herbals:

PAST HISTORY (20 points)

Childhood diseases:

Immunizations:

Allergies:

Blood
transfusions:

Major illnesses:

Injuries:

Hospitalizations:

Labor and
deliveries:

Surgeries:

Use of alcohol:

Use of tobacco:

Use of illicit
drugs:

EMOTIONAL HISTORY (15 points)

Mental, emotional
or psychiatric problems:

FAMILY HISTORY (20 points)

Father:

Mother:

Siblings:

Grandparents:

PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 points)

Occupational
history:

Educational level:

Financial
background:

ROLES AND RELATIONSHIPS (15 points)

Significant
others:

Support systems:

ETHNICITY AND CULTURE (10 points)

Ethnicity and
culture:

Physical and
social characteristics that influence healthcare decisions:

SPIRITUALITY (5 points)

Religious and
spiritual needs:

SELF-CONCEPT (5 points)

View of
self-worth:

Future plans:

REVIEW OF SYSTEMS (20 points) (Please
refer to your assignment guidelines and Chapter 4 of your text. This is not a
physical examination.)

Skin, hair, nails:

Head, neck,
related lymphatics:

Eyes:

Ears, nose,
mouth, and throat:

Respiratory:

Breasts and
axillae:

Cardiovascular:

Peripheral
vascular:

Abdomen:

Urinary:

Reproductive:

Musculoskeletal:

Neurologic:

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