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  • HA Finals Template

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    Wilfredo V. Bello
    12 views7 pages
    This health assessment document contains sections for a patient's profile, vital signs, chief complaint, history of present and past illness, and a head-to-toe assessment. The patient's profile would include their name, age, sex, religion, civil status, occupation, and address. Vital signs such as temperature, pulse rate, respiratory rate, and blood pressure would be recorded. The chief complaint and history of present and past illness provide clinical context. A physical exam is documented covering all body systems from head to toe. The interaction is summarized at the end.

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    This health assessment document contains sections for a patient's profile, vital signs, chief complaint, history of present and past illness, and a head-to-toe assessment. The patient's profile would include their name, age, sex, religion, civil status, occupation, and address. Vital signs such as temperature, pulse rate, respiratory rate, and blood pressure would be recorded. The chief complaint and history of present and past illness provide clinical context. A physical exam is documented covering all body systems from head to toe. The interaction is summarized at the end.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    12 views7 pages

    HA Finals Template

    Uploaded by

    Wilfredo V. Bello
    This health assessment document contains sections for a patient's profile, vital signs, chief complaint, history of present and past illness, and a head-to-toe assessment. The patient's profile would include their name, age, sex, religion, civil status, occupation, and address. Vital signs such as temperature, pulse rate, respiratory rate, and blood pressure would be recorded. The chief complaint and history of present and past illness provide clinical context. A physical exam is documented covering all body systems from head to toe. The interaction is summarized at the end.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 7

    5/16/2023

    Health
    Assessme
    nt

    Name
    BACHELOR OF SCIENCE IN NURSING 1
    PATIENT’S PROFILE

    Name: Age:

    Sex: Religion: Civil Status:


    Occupation/s: Date & Time:
    Address:

    A. VITAL SIGNS
    Body Temperature: Axillary: OC
    Radial Pulse: bpm
    Pulse Rate:
    Apical Pulse: bpm
    Respiratory Rate: Cpm
    Palpatory Method: /P mmHg
    Blood Pressure:
    Auscultation Method: mmHg

    Chief Complain

    History of Present Illness

    History of Past Illness


    B. HEAD-TO-TOE
    FINDINGS
    ASSESSMENT
    Hair, Scalp, Skull, Face

    Eyes and Vision

    Ears and Hearing

    Nose
    Mouth and Oropharynx

    Skin and Nails

    Neck

    Chest and Lungs


    Cardiac and Peripheral
    Vessels

    Breast and Axillae

    Abdomen
    Female/Male Genitourinary
    System

    Anus and Rectum

    Musculoskeletal System
    Sensory-Neurological
    System

    Summary of Interaction

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