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Hello, I am sending you the following assignment to make corrections for me, please. Comprehensive Health Assessment Form
(50 points)
Health History (5 pts total)
Biographical data: (1 pts)
No name or initial required
Age: 65 Marital status: Married since 12-27-1965 S ___Sep. __Cohab.
Birth date: 02-25-1956_____________ Number of dependents: 5
Educational level: High school Gender: Male _____ M _____Other
Occupation (current or, if retired, past): Retired since 2016
Ethnicity/nationality: African Black American
Source of history (who gave you the information and how reliable is that person): Jose Bryan is 75-year-old single woman, retired for 5 years _______________________________________________________________________
Present health history: (4 pts)
Current medical conditions/chronic illnesses: Breast Cancer since 2017, History of high blood pressure since 2019, and asthma
Current medications: Verzinio 200 mg twice daily, taken once in the morning and once at night; amlodipine 5mg once daily (morning); Asmanex/AccolateHistory
Medication/food/environmental allergies: No allergy noted, and no prescription, or over-the-counter medications

Past health history: (10 pts total)
Childhood illnesses: Patient had polio at age of 7, chicken pox at 9 and rubella at age of 11. At this time patient did not obtain the childhood immunization recommended. No ear and throat infections.
Hospitalizations/Surgeries: History of hospitalization at age 35 (March 1981), Jackson Memorial hospital, doing surgery to solve heart problem; Dr. Jodrell Goderich, surgeon
Based on patient’s condition of asthma, he was hospitalized for breathing issues in 2016. Hospitalized in 2019 for chemotherapy and radiation.
Accidents/injuries: No accidents/injuries noted
Major diseases or illnesses: Patient diagnosed for breast cancer in 2017, respiratory issue and being in oxygen.
Immunizations (dates if known):
Tetanus: July 16, 2018 Diphtheria: July 16, 2018 Pertussis ______ Mumps ____
Rubella: July 16, 2018 Polio ___ Hepatitis B: September 7, 2018 Influenza: September 7, 2018 Varicella April 3, 2018 Other __________________
Recent travel/military services: Traveled to Bahamas since January 2017
Date of last examinations:
Physical examination: 03-18-2021 Vision: 02-19-2021 Dental: 04-25-2021
Patient has 20/20 vision on left and right eyes. No history of conjunctivae, no strabismus

Family History (Genogram) (10 points)
Review of Systems (12 points total) Be sure to ask about symptoms specifically.
General health status (1 pt):
History of recent rate change from 213 pounds to 172. Experience of fatigue, depressed, and weakness. Patient has high blood pressure conditions (145/90).
Integumentary (1 pt):
Skin: There is no lesion, no rash in the skin. The skin pigmentation is normal. No history of using sunscreen, and not too much exposition of sun. The temperature is normal, no sign of edema
Hair: History of hair loss after radiation and chemotherapy. No pest resident. According to the genetic background, patient has black hair.
Nails: They are pink and firm with prompt capillary refill.

HEENT (2 pts):
Head: The head is normal, which means no lesions, no presence of parasites, or tenderness. No involuntary movements in the face, it is symmetric, and no weakness. No history of trauma, injury, dizziness, or surgery. No unusually frequent or severe headache. No history of loss of consciousness.
Neck: Everything is normal in the neck. No limitation of motion, no pain, no swelling.
Eyes: No difficulty vision. Absence of pain, lesions, discharge, and inflammation. The patient has a vision 20/20, and he does not wear corrective vision. No history of glaucoma or cataracts
Ears: No hearing impairment. The last test hearing was done on January 10, 2021. No earache, no infections, no discharge, or vertigo. Ears are in good condition. Whispered words are heard bilaterally.
Nose, Nasopharynx, Sinuses: No deformities or tenderness to palpitation. The mucosa is pink, and no lesions: no discharge, no sinus pain, nasal obstruction, epistaxis, or allergy.
Mouth/Oropharynx: The mucosa and gingivae are pink. Loss of 2 molars in the left sifts side and one on the right side. No lesions or bleeding. Multiple dark spots on most teeth. Presence of gums on lower incisors. The tongue is symmetric, and the pharynx is pink—no mouth pains. The patient is able self-care by brushing twice a day.
Respiratory (1 pt.): No history of lung disease, the occurrence of chest pain with difficulty breathing most of the time. No wheezing, no night sweaHistoryhistory of shortness of breath. Colds sometimes, but the patient uses medications over the counter to a threat. The patient occasionally coughs in the morning but without blood. The last x-ray and PPD exams were done on March 18, 2021. No history of smoking
Cardiovascular (1 pt.): Patient suffers about chest pain, palpitation, apnea, and fatigue. Patient experienced hair loss on head and legs, EKG test as done on March 18, 2021, and tested negative. No history paresthesia and heart murmur. History of high blood pressure.
Breasts (1 pt.): (Remember, men have breasts too)
The patient tested positive for breast cancer in 2017 and experienced radiation therapy—history of pain and lesions in the left breast. The contour and consistency are not identical. Retraction in the left breast and non-symmetric comparatively to the right one. No history of performing BSE.
Gastrointestinal (1 pt.):
A recent negative change in appetite, the experience of food tolerance, heartburn, indigestion, and sometimes pain in the abdomen. History of nausea and vomiting without blood. No record of jaundice. A bowel movement every two days and it is formed. No rectal bleeding, pain, or constipation. The last fecal occult blood test was done on March 18, 2021. Colonoscopy tested normal in 2016.
Genitourinary (1 pt.): History No change in the flow of urine, no bloo.history of nocturia.
Female/male reproductive (1 pt.):
Because of the patient conditions since 2017, he is not sexually active; Patient had history of chlamydia in 2019. No occurrence of prostate or scrotal problems.
He does not remember of the date and results of last prostate examination. No lesions in the external area, and no discharge.
Musculoskeletal (1 pt.):
The patient does not experience any joint pain, muscle pain and limitation of motion. No, inflammation of a tendon sheath near the ankle” or “Achilles Tenosynovitis” (Jarvis, 2020, p 611). Movement causes pain. When doing activity, walking, standing, he expressed a kind of weakness in the whole body. The patient never had the History of bone density scan.
Neurological (1 pt.):
No history of stroke, fainting, and seizure. He does not have problem to coordinate. Good ability to speak and swallow, and any deficit of memorization. No history of sensory deficits such as numbness, tingling and loss of sensation, problems with gait, balance.
Psychosocial Profile (10 pts)
Health practices and beliefs/self-care activities:
Patient keeps the routine of brushing, flushing the teeth twice a day, every day. Patient does not able to exercise because of his illness. History of high blood pressure (145/90).
Nutritional patterns: Ask about daily intake (24 hour recall) and appetite.
Patient does have a history of good appetite, and he has the three meals every day. As breakfast, most of the day: Has 2 cups of black coffee -1 piece of bread and butter or peanut butter and jelly
Lunch consists of fruit salad, sugar free jello, and a plain turkey sandwich with lettuce on white bread.
Dinner consists of a turkey plain burger, sliced cucumbers, and sugar free jello
Functional Ability: Patient is very operational and able to preforms daily living activities.

Sleep/rest patterns: Patient usually take a long nap in the morning by 11;00 am and sleep at least 5 hours at night. No sleeping pills
Personal habits (tobacco, alcohol, caffeine, and drugs):
Patient likes drinking black coffee every morning (at least 1 to 2 cups). He does not smoke, drink, or do drugs.
Environmental History: Patient lives in condo in an urban area with his family, which composes of five people
Family/social relationships: Patient is living with family, and he has five kids.
Cultural/religious influences: Patient is catholic
Mental Health: Patient feels depressed about his problems
Now answer the question below: (3 pts)
Using the instructions below, identify 1 physical strength, 1 psychosocial/cognitive strength, and 1 weakness in either category. State why you think this to be true.
This documentation is concerned this 65-years-old man who was tested positive with cancer since 2017. After doing chemotherapy and radiation many times, his situation risks to becoming more complicated. The difficulties are the following: hair loss, fatigue, discomfort when standing and walking. He also develops high blood pressure which puts him at a high risk of developing other disease. However, even his problems, he is able of performing the activities of daily living and continuing to develop a good relationship with friends and family. Although is complications, the patient also maintains a great sleep schedule with excellent neurological health, and he tries to keep a good eating habit. The patient does not any mental issue. He is able to speak with regular coordination.

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