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Biographical data Assignment PDF

   

Added on  2021-05-30

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Date .......................................................................................Interview conducted by ......................................................Designation ..........................................................................1. Biographical dataName Trudy Green...................................................................................................................................................................................Address 1208 Happy Valley.....................................................................................................................................................................Date of birth 12th October 1989 Birthplace Ashtyn......Age 24 Gender female Marital status single.............................................................................................................Occupation teacher...................................................................................................................................................................................Employer not mentioned...........................................................................................................................................................................Nationality Australia Interpreter required? no................................................Medicare number (Not required for the assignment) not discussed........................................................................................................Private Heath Fund Details (Not required for the assignment) not discussed........................................................................................Advanced care directive? Details: no...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................2. History obtained from patient herself.....................................................................................................................................................3. Reason/s for seeking care health check-up...............................................................................................................................................................................................................................................................................................................................................................4. Present health or history of present illness mild colds sometimes.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................5. Past healthGeneral health .........................................................................................................................................................................................................................................................................................................................................................................................................Childhood illnesses asthma and size eyes.................................................................................................................................................................................................................................................................................................................................................................Accidents or injuries ...................................................................................................................................................................................................................................................................................................................................................................................................Serious or chronic illnesses chronic sinusitis.............................................................................................................................................................................................................................................................................................................................................................Hospitalisations sinus on teeth...................................................................................................................................................................................................................................................................................................................................................................................Operations sinus on teeth...........................................................................................................................................................................................................................................................................................................................................................................................Obstetric history no...................................................................................................................................................................................Gravida ...................................... Term ...................................... Preterm ............................................(# Pregnancies) (# Term pregnancies) (# Preterm pregnancies)Term / Incomplete ..................................... Children Living .............................................................................................................Source: Jarvis, C & Denmead, E (Australian adapting author) 2012, chapter 7 ‘The health history’, in Student laboratory manual for physical examination and health assessment, Australian and New Zealand edition, Saunders Elsevier, Sydney, pp. 65–73.NURS1004 Part 1 Documentation for Health assessment

(# Terminations / Miscarriages) Course of pregnancy no.............................................................................................................................................................................................................................................................................................................................................................................................(Date delivery, length of pregnancy, length of labour, baby’s weight and sex, vaginal delivery / caesarean section, complications, baby’s condition)ImmunisationsTetanusCurrentSelect........................................................................................................................InfluenzaCurrentSelect flu shot coming up............................................................................................PneumococcusCurrentSelect........................................................................................................................Other ........................................................................................................................................................................................................................................................................................................................................................................................Last GP visit date five or six weeks ago...................................................................................................................................................Health ScreeningDentist five or six weeks ago Vision .......................regular check up done two weeks ago to check updates................Hearing two years ago ECG done when young.......CXR ......................................................................... Other .......................................................................................Allergies: Allergens and reaction – allergy bracelet applied Select...............................................................................................Drugs / medications ...............................................................................................................................................................Food preservatives 220............................................................................................................................................................Latex / other cats, grasses, ponds...........................................................................................................................................Comments ...............................................................................................................................................................................................................................................................................................................................................................................Infection controlTransmission-based precautions cleaning before eating and during toileting to be hygienic.................................................Notifiable disease ..................................................................................................................................................................6. Family historyHeart disease paternal grandparents.......................................................................................................................................................High blood pressure mother.....................................................................................................................................................................Stroke both side of family.........................................................................................................................................................................Diabetes both side type 2.........................................................................................................................................................................Blood disorders no....................................................................................................................................................................................Breast cancer father side, aunty died at her 40s......................................................................................................................................Cancer (other) no......................................................................................................................................................................................Sickle cell no.............................................................................................................................................................................................Arthritis both side......................................................................................................................................................................................Allergies ....................................................................................................................................................................................................Asthma mom has asthma.........................................................................................................................................................................Obesity no.................................................................................................................................................................................................Alcoholism no...........................................................................................................................................................................................Mental illness no.......................................................................................................................................................................................Seizure disorder no...................................................................................................................................................................................Kidney disease no.....................................................................................................................................................................................Tuberculosis no........................................................................................................................................................................................Other no....................................................................................................................................................................................................Review of symptoms, function and risksInclude both past health problems that have been resolved and current problems, including date of onset.7. General overall health and wellbeingPerception of health moderately fit.............................................................................................................................................................................................................................................................................................................................................................................Page 2 of 7

..................................................................................................................................................................................................................Interpersonal relationships / resources lives with partner........................................................................................................................Education (last level achieved) masters...................................................................................................................................Current employment teacher....................................................................................................................................................Family role? .............................................................................................................................................................................Support systems? no................................................................................................................................................................Values and beliefs / spiritual resources catholic and celebrates Easter and Christmas..........................................................................Cultural background ...............................................................................................................................................................Cultural health practices ........................................................................................................................................................Religious / spiritual beliefs .....................................................................................................................................................Coping and stress management ............................................................................................................................................................Stressors in life? Stress, ulcers................................................................................................................................................Methods to relieve stress try to avoid acidic foods, shops chocolates....................................................................................Self-concept ...........................................................................................................................................................................................Personal strengths? Confident and happy person...................................................................................................................Life values and belief everyone should have the scope to research potential in education....................................................Sleep / rest 10.30 to 11.00.......................................................................................................................................................................Sleep pattern? Playing solitaries, browsing net.......................................................................................................................Aids used? .............................................................................................................................................................................8. Health and lifestyles managementCurrent medications: (prescribed and OTC). Note name, purpose, dose and daily schedule.Ask specially about vitamins, oral contraceptives, aspirin, sedatives and antacids.Azatec, histamine, asthma relievers, penicillin...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Tobacco, alcohol and recreational / street drugsSmoke cigarettes? no Number of packs per day ....no......................................................................................................................Daily use for how many years ...................... Age started ..............................................................................................Ever tried to quit? ......................................... Succeed? .................................................................................................Comments ..............................................................................................................................................................................Drink alcohol? occasionally Date last alcohol use two weeks ago......................................................................................................Amount of alcohol that episode apple cider..............................................................................................................................Out of the last 30 days, how many days had alcohol? twice...................................................................................................Ever had a drinking problem? no.............................................................................................................................................Comments ..............................................................................................................................................................................Any use of recreational drugs? (reinforce confidentiality of information disclosed)noWhich ones ...................................................................Marijuana? ..................................................................... Cocaine? ....................................................................................Crack cocaine? .............................................................. Amphetamines? ........................................................................Barbiturates? ................................................................ LSD? ...........................................................................................Heroin? ........................................................................ Other? .......................................................................................Ever had treatment for drugs or alcohol? ................................................................................................................................Other comments? ....................................................................................................................................................................................................................................................................................................................................................................................................Environmental hazards ..........................................................................................................................................................................Live alone? With family? partner..............................................................................................................................................Neighbourhood? Not friendly....................................................................................................................................................Page 3 of 7

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