Complete Health History
Complete Health History
• Biographical Data J.S. 67 year-old, white-female, widowed, resides in central Florida, retired RN, adopted (parents unkown). • Source of History Client-patient. • Is this a reliable source? Yes. • Reason for Seeking Care Routine visit. • Present Health or History of Present Illness Irregular bowel movements: constipation “Constipation aside I feel healthy and happy. It’s unfortunate how uncomfortable not being able to move bowels are. Everyday it’s the same thing and I get upset that it’s happening to me. It’s disruptive. On a scale from 1-10, 10 being the most severe I would say I am at a 6-7 on a daily basis when it comes to discomfort and pain.” • Past Health Mumps at 12 years of age and chickenpox at 5 years of age. Burned forearm with sparklers which results to deep burns and scarring. Elective breast reduction in 1988. Obstetric history: G4, P3, A1. Primary physician physical done annually, last 5/2012. Due to the diligent visits annually with PCP all vaccines are up to date (influenza, Td/Tdap, Varicella, HPV, Zoster, MMR, Pneumococcal, Meningococcal, Hep A and B). Dental and vision exams every 2 years, both last 5/2012. • Family History Because client is adopted at birth and parents are unknown familial history is unavailable. • Review of Systems o General Health Present weight 154 lbs. Client states, “I’ve been this weight for approximately 25 years and I’m always trying to rid myself of 5-8 lbs. I walk 10 km per week.” States the absence of fatigue, weakness, fever, chills or night sweats. o Integumentary Mild eczema behind knees, bilaterally. Absences of pigment or color change, moles, excessive bruising, rashes or lesions. Client states, “I deal with my eczema with ointments that keep the problem at-bay with products from Whole Foods. It’s really a non-issue.” o Hair Absence of hair loss or change in texture. “I color my hair every 6-7 weeks religiously.” o HEENT Head: Frequent or severe headaches are not present. No head
• Biographical Data J.S. 67 year-old, white-female, widowed, resides in central Florida, retired RN, adopted (parents unkown). • Source of History Client-patient. • Is this a reliable source? Yes. • Reason for Seeking Care Routine visit. • Present Health or History of Present Illness Irregular bowel movements: constipation “Constipation aside I feel healthy and happy. It’s unfortunate how uncomfortable not being able to move bowels are. Everyday it’s the same thing and I get upset that it’s happening to me. It’s disruptive. On a scale from 1-10, 10 being the most severe I would say I am at a 6-7 on a daily basis when it comes to discomfort and pain.” • Past Health Mumps at 12 years of age and chickenpox at 5 years of age. Burned forearm with sparklers which results to deep burns and scarring. Elective breast reduction in 1988. Obstetric history: G4, P3, A1. Primary physician physical done annually, last 5/2012. Due to the diligent visits annually with PCP all vaccines are up to date (influenza, Td/Tdap, Varicella, HPV, Zoster, MMR, Pneumococcal, Meningococcal, Hep A and B). Dental and vision exams every 2 years, both last 5/2012. • Family History Because client is adopted at birth and parents are unknown familial history is unavailable. • Review of Systems o General Health Present weight 154 lbs. Client states, “I’ve been this weight for approximately 25 years and I’m always trying to rid myself of 5-8 lbs. I walk 10 km per week.” States the absence of fatigue, weakness, fever, chills or night sweats. o Integumentary Mild eczema behind knees, bilaterally. Absences of pigment or color change, moles, excessive bruising, rashes or lesions. Client states, “I deal with my eczema with ointments that keep the problem at-bay with products from Whole Foods. It’s really a non-issue.” o Hair Absence of hair loss or change in texture. “I color my hair every 6-7 weeks religiously.” o HEENT Head: Frequent or severe headaches are not present. No head