| Course | NUR 607 Advanced Health Assessment |
|---|---|
| Module | Module 3 |
| Paper type | Milestone: comprehensive health history with screening plan |
| Length | About 1,030 words, 6 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NUR 607 Module 3
Milestone One: Comprehensive Health History and Screening Plan for a 34-Year-Old Woman Establishing Care
[Student Name]
Southern New Hampshire University
NUR 607: Advanced Health Assessment
Milestone One
[Instructor Name]
[Date]
The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.
Milestone One: Comprehensive Health History and Screening Plan for a 34-Year-Old Woman Establishing Care
A comprehensive health history is the widest lens in primary care. At a first visit it establishes baseline information that will guide care for years, and it often uncovers risks that no single complaint would reveal. This milestone documents the full history of a new adult patient in standard order, keeping everything she reports in the subjective record, and then derives a screening plan from her age, sex and history. It argues that the value of a comprehensive history lies in the connections it makes, such as a family history that changes when screening should begin, rather than in the number of boxes it fills.
Identifying Data and Reason for Visit
Ms. R., 34, works as a pharmacy technician and is the source of this history and appears reliable. She relocated here from Ohio in the spring and has come to establish care. She has no acute concerns but mentions feeling tired in the afternoons for several months, which she attributes to her work schedule and two young children.
Present Health and Fatigue
She describes the fatigue as a need to sit down between 2 and 4 p.m. on most weekdays for about six months, without falling asleep unintentionally. She sleeps about six hours a night, is woken by her 2-year-old once or twice and does not snore to her partner's knowledge. Her mood is "mostly fine," though she feels stretched. Her periods are regular every 28 days and heavy on the first two days, soaking a pad every two to three hours. She denies weight loss, fever, shortness of breath and changes in bowel habits.
Past Health History
Medical: gestational diabetes in her second pregnancy, treated with diet, with a normal glucose tolerance test at 12 weeks postpartum; she has had no glucose testing since. Seasonal allergic rhinitis. Surgical: cesarean birth 2 years ago. Obstetric: gravida 2, para 2; vaginal birth 6 years ago; cesarean birth 2 years ago for failure to progress. Medications: cetirizine 10 mg daily in spring; no supplements. Allergies: penicillin, which caused hives as a child. Immunizations: she believes she had a tetanus booster during her last pregnancy; she has not had a COVID-19 or influenza vaccine this season; hepatitis B series and HPV status unknown. Last cervical screening: cytology 3 years ago, reported normal.
Family History
Mother: 61, breast cancer diagnosed at 44, treated with surgery and chemotherapy, alive; genetic testing status unknown. Father: 64, type 2 diabetes and hypertension. Maternal aunt: ovarian cancer at 58, deceased at 60. Maternal grandmother: died at 72 of a stroke. Paternal grandparents: grandfather had a myocardial infarction at 58; grandmother alive at 86. Brother: 31, healthy. Children: 6 and 2, healthy. No known colon cancer, early sudden death or bleeding disorders.
Personal and Social History
She lives with her partner and two children in a rented house. She completed a pharmacy technician certificate and works 36 hours a week, mostly standing. She has never smoked, has wine with dinner on Saturdays, usually a glass, occasionally two and denies cannabis or other drug use. She walks 20 minutes on three days a week. Her diet includes fast food about twice a week. She feels safe at home; in response to a direct question, she reports no current or past physical, sexual or emotional abuse by a partner. Sexual history: one male partner for eight years; no history of sexually transmitted infections; not currently using contraception and "would not mind" a third child in the next year or two. She wears a seat belt, and there are no firearms in the home. She has a dental cleaning every year and last had an eye examination for her contact lenses 18 months ago. Her main source of stress is child care during her shifts, which her partner and a neighbor share.
Review of Systems
General: fatigue as above; no fever or night sweats. Skin: no rashes or changing moles. Eyes: wears contact lenses; no vision change. Ears, nose and throat: seasonal congestion; no hearing loss. Breasts: no lumps, discharge or skin changes; she does not do regular self-examination. Cardiovascular: denies chest pain, racing heartbeat or ankle swelling. Respiratory: denies cough or wheeze. Gastrointestinal: no heartburn, abdominal pain, blood in stool or change in bowel habit. Genitourinary: no dysuria or frequency; heavy menses as above. Musculoskeletal: aching feet after long shifts. Neurologic: no headaches, numbness or weakness. Psychiatric: feels stretched; denies persistent low mood, loss of interest or thoughts of self-harm; feels worried "more than I should" some weeks. Endocrine: no heat or cold intolerance, excessive thirst or urination. Hematologic: bruises easily with heavy periods; no bleeding gums.
Screening and Health Promotion Plan
Cervical cancer: she is due for screening at 34, three years after normal cytology; options are cytology every three years or high-risk HPV testing, alone or with cytology, every five years from age 30 (US Preventive Services Task Force, 2018a). Hereditary breast and ovarian cancer: a mother with breast cancer at 44 and a maternal aunt with ovarian cancer call for a familial risk assessment tool, and a genetic counseling referral if it scores her as increased risk (US Preventive Services Task Force, 2019). Depression and anxiety: both screenings are recommended for adults of her age, and her report of excess worry makes a PHQ-9 and GAD-7 today appropriate (US Preventive Services Task Force, 2023). Intimate partner violence: screening women of reproductive age is recommended, and her negative screen is documented (US Preventive Services Task Force, 2018b). Other items: HIV and hepatitis C screening once; a complete blood count and ferritin for fatigue with heavy menses; glucose or hemoglobin A1c testing because of prior gestational diabetes; a daily folic acid supplement of 400 to 800 mcg because she may conceive; influenza and COVID-19 vaccines today and a review of hepatitis B and HPV vaccination.
Conclusion
This comprehensive history establishes Ms. R.'s baseline and shows how sections connect: heavy menses and fatigue point to anemia testing, prior gestational diabetes to glucose testing, pregnancy plans to folic acid and a three-generation family history to a hereditary cancer risk assessment. Milestone Two will add the physical examination to complete the database.
References
US Preventive Services Task Force. (2018a). Screening for cervical cancer: US Preventive Services Task Force recommendation statement. JAMA, 320(7), 674-686. https://doi.org/10.1001/jama.2018.10897
US Preventive Services Task Force. (2018b). Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: US Preventive Services Task Force final recommendation statement. JAMA, 320(16), 1678-1687. https://doi.org/10.1001/jama.2018.14741
US Preventive Services Task Force. (2019). Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer: US Preventive Services Task Force recommendation statement. JAMA, 322(7), 652-665. https://doi.org/10.1001/jama.2019.10987
US Preventive Services Task Force. (2023). Screening for depression and suicide risk in adults: US Preventive Services Task Force recommendation statement. JAMA, 329(23), 2057-2067. https://doi.org/10.1001/jama.2023.9297
What the NUR 607 Module 3 instructions ask for
Milestone One in NUR 607 generally asks for a comprehensive health history of an adult, real or simulated, in standard order: identifying data and source, reason for visit, present health, past medical, surgical, obstetric and medication history, allergies, immunizations, family history, personal and social history and a complete review of systems. Many versions also ask for a screening or health promotion plan. Expect four to six pages in APA 7, using your section's template if one is provided. Keep everything the patient reports in the subjective record, record unknowns as unknown and connect the history to the screening plan, since that connection is what separates a comprehensive history from a completed form. Proofread names and dates carefully.
How this NUR 607 Module 3 milestone one example is built
The sample documents a composite 34-year-old pharmacy technician establishing care. It develops her one complaint, afternoon fatigue, along with sleep and heavy menses, then records past, obstetric and medication history with unknown vaccine status noted as unknown. The family history spans three generations with ages at diagnosis, including a mother with breast cancer at 44 and an aunt with ovarian cancer. Social history covers habits, pregnancy plans and a directly asked partner violence screen. A complete review of systems stays in her words. The screening plan cites USPSTF recommendations for cervical cancer, BRCA risk assessment, depression and partner violence, and adds anemia, glucose and folic acid items drawn from her history.
Where the NUR 607 Module 3 rubric puts the points
Comprehensive history rubrics in this course usually score completeness of each section, correct order and format, depth of the present health and family history, a complete and subjective review of systems, a screening plan based on current recommendations and professional writing in APA 7. Top-band work records ages at diagnosis in the family history, documents the source and reliability of the history and treats unknowns honestly. Graders reward plans in which screening decisions are linked to specific history findings and cite the recommending body with its year. Asking sensitive questions directly, such as partner violence and sexual history, and recording the answers is often a separate rubric item.
NUR 607 Module 3 help: the mistakes that cost points
Comprehensive histories lose points when sections are skipped, when the family history lists diseases without ages or relationships, when the review of systems includes examination findings or repeats the present illness or when the screening plan is generic. Another common error is citing outdated screening intervals. Follow the standard order, record ages at diagnosis, keep the review of systems subjective, state unknowns and derive each screening item from her age, sex and history with a current citation. If your patient is male, older or pregnant, or your instructor uses a specific template, send it along with the scenario for a history built to that format and those recommendations, section by section.
Get NUR 607 Module 3 written to your instructions
Send your template, the patient scenario or your interview notes and the milestone rubric. A comprehensive history in standard order, with a subjective review of systems and a screening plan tied to current recommendations, will be ready in 24 to 48 hours, and the first one is free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
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NUR 607 Module 3 questions, answered
Where can I find a free NUR 607 Module 3 Milestone One sample?
A complete milestone is published on this page: a comprehensive health history for a 34-year-old woman establishing care, with a screening plan tied to current USPSTF recommendations.
Which parts make up a full adult health history?
Identifying data and source, reason for visit, present health, past medical and surgical history, medications, allergies, immunizations, family history, personal and social history and a complete review of systems.
How detailed should the family history be?
Cover at least three generations, recording each relative's relationship, current age or age at death and age at diagnosis of significant conditions, since these details determine hereditary risk.
When should a family history of breast cancer prompt genetic counseling?
The USPSTF recommends a familial risk assessment tool for women with a personal or family history of breast, ovarian, tubal or peritoneal cancer, with genetic counseling if the tool indicates increased risk.
What cervical screening options apply at age 34?
From age 30 to 65, the USPSTF supports cytology every three years, high-risk HPV testing every five years or HPV testing with cytology every five years.