NR 548 Week 4 Psychiatric History Assignment Template (Initials; CS)

Claritin 10ml As needed Seasonal allergies n/a Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text. enter text. text. to enter text. n/a Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text. enter text. text. to enter text. n/a Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text. enter text. text. to enter text. n/a Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text. enter text. text. to enter text. Past Psychiatric History - Includes all previous mental health psychotherapy and medication management. Be as descriptive as possible. Include type of provider, name if provided, year(s) of treatment, types of services received, history of trauma, self-harm or harm to others. Patient states that he has a history of having anxiety but is not currently seeing a provider or taking medication for it. Patient states that he has been dealing with anxiety for the past 2 years. Medical History (PMHx) – Includes active medical problems (currently getting managed) and past medical problems (no longer needing any intervention), hospitalizations, and surgeries. Depending on the CC, more info may be needed. Patient had right knee surgery in 2005. Patient denies any other surgeries or hospitalizations. Family History (Fam Hx) - History includes, but it is not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Mother is alive and has no medical history. Father is alive and vertigo. Brother is alive and has no medical history. Grandmother is alive is a current smoker and has hypertension and diabetes type 2. Respiratory Neuro Cardiac and Respiratory MSK If patient denies all symptoms for this If patient denies all symptoms If patient denies all symptoms for this If patient denies all symptoms system, check here: ☒ for this system, check here: system, check here: ☒ for this system, check here: ☒ ☐ ☐ Cough Click or tap here to ☐ Syncope or ☐ Chest pain Click or tap here to ☐ Pain Click or tap enter text. Lightheadedness Click or tap enter text. here to enter text. ☐ Hemoptysis Click or tap here to enter text. ☐ SOB Click or tap here to enter ☐Limited ROM here to enter text. ☐ Headache Click or tap text. Previous cardiac history Click or ☐ Dyspnea Click or tap here to here to enter text. tap here to enter text. ☐ Redness Click or tap enter text. ☐ Numbness Click or tap ☒Other: Patient admits to having here to enter text. ☐ Wheezing Click or tap here to here to enter text. palpitations, when feeling stressed or ☐involuntary movements enter text. ☐ Tingling