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Health History Example

Health History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History Example

Uploaded by

Jo Mesias
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2K views

Health History Example

Health History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History ExampleHealth History Example

Uploaded by

Jo Mesias
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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Complete Health History Assignment

STUDENT NAME:

Biographical Information
DOB: 10/06/1987 Gender: female Race: Caucasian Ethnicity: French Additional (Insurance information)

Source and Reliability


Where does the information come from What indicators of reliability are there

Reason for Seeking Care


CC: headache

History of Present Illness (HPI)


Throbbing for the past two hours, can feel pulse in temples, 4 on a scale of 1-10, started while in the student center checking her mailbox; other symptoms: thirsty; has not taken any medications

Past Medical History


General State of Health: good Past illnesses: none Chronic Illnesses: minor scoliosis (no pain or limitations) Injuries and treatments: broken toe in first grade (had crutches); visited a chiropractor Hospitalizations: none Surgeries: wisdom teeth removed (Dec. 2002) Active/Chronic Problems: sports-induced asthma; no limitations; not being treated Allergies o Seasonal; no food allergies o Drugs See medication history below: had a drug reaction to an unknown asthma medicine at age 8 Substance use/abuse o No tobacco use. Drinks wine ~once/month o Recreational drugs: none

Exercise: running once every 2 weeks; trying to exercise more regularly; does Yoga once every 2 weeks Nutrition: neither overly unhealthy nor healthy Sleep Pattern: tries for 8 hours every night; a short nap every couple days

Medication History
Current medications: none Vitamins: no, feels she should Herbal remedies/health supplements: none Past medication: Albuterol, d/cd 2 years ago o Dose: 1 to 2 puffs as needed o Reason for taking: asthma o Reason for d/c: no need for it; Past medication: Benzaclyn d/cd six months ago o Dose: topical o Reason for taking: acne o Reason for d/c: trying to find something that would work better Past medication: another asthma medication (does not recall what) o Dose: 1 puff a day in season o Reason for taking: asthma o Reason for d/c: rash Allergies/ADRs: o unknown asthma drug; rash at age 8. No treatment other than stopping the drug.

Health Maintenance
Immunizations: up to date Frequency of physicals or routine care: annually Gynecological exams Frequency and last: none Eye: every other year Cholesterol: whenever she donates blood; 197-203 Self breast and testicular exams: no Seat belts, bike helmets: yes, no Efforts to change: trying to exercise more Diets:no particular

Environmental Health
Occupation: student and Resident Assistant; after-school care supervisor Nature of Work: 20 hours a week, variety of tasks, supervision, rule enforcement; supervise small children Work setting sun, office building; residence hall; classroom, cafeteria, playground Exposure to hazardous materials and loud noises: no Hobbies: reading, spending time with people, cross stitching Work related symptoms: occasional headaches; no treatment Travel history: UK, Caribbean, throughout USA

Family History (Genogram or list)


Health status (living, dead, ill): past 2 generations still living, except for an uncle Diseases: maternal grandparents diabetes, mother skin cancer, paternal grandmother breast cancer, several high cholesterol, high BP Hereditary and environmental factors: alcohol abuse

Psychosocial and Spiritual History


Tell me about yourself: average girl, enjoy life, not suicidal, moderate amount of stress Upbringing: raised in a 2-parent home in a small town with 3 siblings Marital status, roommates: single, no longer has a roommate Support network, friends: good Perceptions of healthcare: beneficial, especially if covered by insurance Perceptions of and satisfaction with life: its good, she likes her life How has illness impacted life: creates the occasional discomfort Religious beliefs, practices: Christian (Presbyterian); attends church weekly Prayer or meditation: yes, small bits each week

Sexual History
Sexual drive as an indicator of overall health: believes it is normal Perception of sexuality: natural aspect of personality related to attraction between the sexes; heterosexual; monogamous but not active Frequency and nature of sexual activity: non-existent Age of first experience: N/A Sexual problems: N/A STDs: N/A Risk behaviors: N/A Sexual orientation: heterosexual Abuse/Rape: no Number of pregnancies, terminations: none Trying to become pregnant: no LMP: two weeks ago Menopause: no

Review of systems
Constitutional symptoms (e.g., fever, weight loss): negative Eyes: negative Ears, Nose, Mouth, Throat: negative Cardiovascular: negative Respiratory: negative except past history of asthma Gastrointestinal: negative Genitourinary: negative Musculoskeletal: negative Integumentary (skin and/or breast): negative Neurological: negative except headaches (see HPI above)

Psychiatric: negative Endocrine: negative Hematologic/Lymphatic: negative except iron too low to donate blood, but still w/n healthy limits Allergic/Immunologic: negative except for seasonal allergies.

ROS specific HPI


Seasonal allergies worse in the spring. Thinks it is from pollen. Runny nose and itchy eyes. No congestion. Lasts about two months. Occasionally takes Claritin OTC seems to help. Is worse in West Palm Beach than back home in Colorado.

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