Health History guidelines and grading rubric

To complete the information below, use the Health History standards and grading rubric contained in Course Materials. This assignment is worth 200 points, with 10 points provided for writing clarity, which includes good punctuation, spelling, and medical terminology.

Fill out this form with your responses. Save the file with the assignment name and your last name, such as NR305 Milestone1 Form Smith. When you're ready, upload the completed form to the Milestone #1 Dropbox by the time specified in your guidelines. If you have any issues about this project, please post them in the Q&A Forum or contact your instructor. 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.



July 27, 2017


K. N


26 years Old

Date of birth:

09th November 1991


New York



Marital status:



African- American




Office Assistant, and part time student

Health insurance:


Source of information:

Patient himself

Reliability of source of information:

The patient seems highly reliable. He seems well and is an excellent communicator. He is reliable because he gives similar answers to specific questions even when they are paraphrased later in the interview


The reason for seeking care:

A persistent skin disease. The participant states that “I have decided to apply for health care because I have been experiencing skin rashes on my back and arms. This condition has been persistent for a long time.

Location: The majority skin rashes are at the upper back. The rashes spread from the neck to the shoulders. The rashes are also present on the right-hand arm (near the elbow) and the right thigh. There is also one large skin rash along the patient's rear hairline. The client also confirms that there are rashes on his scrotum.

The character of quality: These hives are large, gray and white, and round.

Quantity or severity: there are numerous amounts of rashes on the upper back near the neck and shoulders. The severity of the outbreaks decreases as one descends along the backbone. There are more hives on the arm than on the thigh. The patient says that "the number of rashes on my back and legs is so high that I fear to remove my clothes during swimming practices or around people. “

Timing: the patient states that "I first noticed the skin rashes on my arm in November 2015. The condition had lasted for about a month before I sought treatment. Since then, the condition disappears and appears. I have sought treatment for some times, but the situation keeps reappearing.

Setting: the condition started shortly after I joined boarding school.

Aggravating or Relieving Factors: the patient is not sure which treatment best aggravates the condition. I have tried some treatment options ranging from western to traditional medicine.

Associated Factors: this condition is associated with itching and scratching. The associated symptoms are severe during hot weather. Nonetheless, oiling the skin and applying anti-fungal creams slightly relieves the state. The patient says that "among the various kinds of ointment that I have used in the past, anti-fungal creams seem to help the most."

Patient’s perception: The patient's claims that this condition has significantly affected his daily activities. Although he was happy upon joining the school’s swimming team, he states that the skin condition discourages him from actively engaging in the activities. Unlike before, he cannot remove his shirt when with teammates or around other people. He fears disqualification by the team manager on health conditions and isolation by his friends.

Using Gordon’s functional health patterns model, it is evident that the client’s general health is above average. He is strong and denies suffering from any cold or flu in the past one year. He has never missed a day from work or school due to health related complications. Recently, the participant joined the school's swimming team and has been attending swimming lessons that include other physical activities. He denies any Being an athlete, the patient

of drugs, alcohol, and cigarettes.

Use of drugs, alcohol, and cigarettes.

Health goals:

As an athlete, the patient defines health as a body state where one has no disease, illness, or injury that hinders one’s participation in sports. Health is the overall state of well-being in body and mind. Currently, the participant considers his condition as unhealthy due to the itchy skin rashes on his body parts. He is concerned that the skin condition may aggravate leading to increased rashes, itching, and disqualification from the school’s team, and social isolation by friends and peers. In future, the patient thinks that the skin condition will either increase or decrease depending on the actions that he takes now. He expects that the health practitioners will prescribe a treatment that will reduce and eradicate the skin condition.


Beliefs and practices:

Being a staunch Christian, the patient believes that his body is the temple of the Holy Spirit. Therefore, he engages in practices that aim to uphold the sanctity of the body. For instance, he does not engage in drugs and alcohol and regularly exercises to improve his body image.

Factors influencing health care decisions:

Religion: The patient considers his body as a temple of Holy Spirit. Therefore, the body should be healthy.

Income: the patient admits that he could seek health care regularly if he had adequate income.

Social Association: Being in the school's swimming team, the patient decided to find healthcare to avoid social isolation.

Related traits, habits or acts:

Healthy eating and regular exercises.

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

Prescription drugs:

Nizoral Cream 3*/day for two weeks from January 4th, 2016


1 cup of boiled Prickly chaff flower* 14 days from March 20th, 2016.

Onion extract gel 1*1 for one month.

PAST HISTORY (20 points)

Childhood diseases:



H. Influenzae (Hib)

Polio (IPV)

Chickenpox (varicella).

Pneumococcal (PCV 13).

tetanus-diphtheria-pertussis (Td/Tdap



Blood transfusions:


Major illnesses:






Labor and deliveries:




Use of alcohol:


Use of tobacco:


Use of illicit drugs:



Mental, emotional or psychiatric problems:

The patient has never experienced any major mental, emotional, or psychiatric complication.

FAMILY HISTORY (20 points)


Has been suffering from arthritis for four months since January 2017


Does not have any major complication. Experienced a car crash in August 2016. Limps slightly.


Three siblings. All are mental, emotionally, and physically healthy.


Both died of diabetes-related complications


Occupational history:

The client is currently working as an office assistant in a clearing and forwarding company. A position he has held for two years. Previously, K.N was working as an intern in an electric company.

Educational level:

First year in an undergraduate program

Financial background:

Low income


Significant others:

1 Wife, three siblings, and two parents.

Support systems:

The patient admits that he has a well-developed support system. More specifically, he states that he can talk to his wife, colleagues, and some family members regarding any health or personal problem. The patient describes any time spent with his wife, friends or family like the best.


Ethnicity and culture:

African-American ethnic group and culture. Considers health as the wellbeing of an individual's spirit and body and having useful social links.

Physical and social characteristics that influence healthcare decisions:

The client is worried that the skin condition hinders his swimming activities and risks social isolation from friends.


Religious and spiritual needs:


SELF-CONCEPT (5 points)

View of self-worth:


To be 100 percent healthy, participate in the swimming team, and care for his family.

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:

Dry and itchy skin, circular gray patches

Head, neck, related lymphatics:

No Change


No Change

Ears, nose, mouth, and throat:

No Change


No Change

Breasts and axillae:

No Change


No Change

Peripheral vascular:

No Change


No Change


No Change


No Change


No Change


No Change


Hay, R. J., Johns, N. E., Williams, H. C., Bolliger, I. W., Dellavalle, R. P., Margolis, D. J., ... & Michaud, C. (2014). The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions. Journal of Investigative Dermatology, 134(6), 1527-1534.

Lupton, D. (2012). Medicine as Culture: Illness, disease, and the body. Newcastle: Sage.

Rachakonda, T. D., Schupp, C. W., & Armstrong, A. W. (2014). Psoriasis prevalence among adults in the United States. Journal of the American Academy of Dermatology, 70(3), 512-516.

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