What factors could impact this person’s ability to seek/receive follow up care (i.e. cost, lack of motivation, transportation etc.)?

NUR 315: Health Assessment for the Registered Nurse

Health History Assignment

Date of Interview: 1/10/19

Patient Information/Health History

Sex:  q Male  q Female q Other                       Age:  __45____

What does the person consider his/her primary health concerns? Interstitial cystitis

Do these health concerns interfere with:  q Work?     q Sleep?     q Leisure Activities?

If yes, please explain: Intermittent pain and spasms. Time spent under heating blanket. Pain relievers. Bladder distension q 6 months

List any current medical, behavioral, or mental disorders: GERD, Interstitial Cystitis (IC)

List any other relevant past medical, behavioral, or mental disorders and dates:

List the approximate dates and type of any past surgeries: Appendectomy (July 1999), C-section (Jan 2013)

Does the person experience pain on a regular basis? YES

If yes, please describe the nature/type of pain and rate it on a scale of 1-10 (10 is most severe): “Pressure”, “Burning”

Current dietary practices: Eats about 2 meals a day

Current sleep patterns (adequacy and amount): Poor sleep. 5-6 hours a night

Describe past and current tobacco use: None

Describe past and current alcohol/drug use: Social less than 1 a month

Does the person have any allergies? NSAIDS

Can the person care for him/herself?  If not, how is care managed? Person care for self

Psychosocial history (include occupation, education, family responsibilities, social support, religious preferences, cultural influences): Pt states she is a consultant. BA in criminal justice. Married with 1 daughter. Social support from husband. “in fight with her sister” Pt states she is Jewish and tries to attend services regularly. Pt has strong religious belirfs

List all medications, dose, schedule, and reason for taking:

Omeprazole 40 Mg daily for reflux

Uribel PRN for bladder spasms

Hydrocodone 5/325 PRN for bladder pain

MVT Daily

Birth Control Pills Daily


Enter a 1 for a current problem and 2 for a past problem

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