Health History Form
Health History Examination Form
Verbal History Student Name: Date: Client Name: Age: _34_Sex: _F__Marital Status: Married
Race including Ethnic Affiliation: _Caucasian_Religion: Christian_
Current Occupation: Pharmacy technician_
Birthplace: Oklahomia City, OK
Chief Complaint: Headaches History of Present Illness or problem: Patient stating that headaches have been occurring more often and severity is worse. Patient states this began about a month and a half ago. Two to three a week per patient. Patient also has complaints of nausea, vomiting, neck tension, and photosensitivity. Past Medical History: Patient has a medical history of hypertension diagnosed in 2010. For which she takes an ACE Inhibitor for. Patient has also had a history of one vaginal birth with no complications. Childhood Illness: Patient denies any illnesses or diagnoses prior to 2010.
Immunizations: Patient states her immunizations are required to be up to date by her employer.
Allergies (past and present)
Food: ________None applicable ____
Medications: _ None applicable__
Environmental: __ None applicable ____ Current Medications including OTC: Lisinopril 20mg, Mirena
Hospitalizations/Serious Illness/Surgery, include year: Vaginal non complicated delivery 2009
Accidents/Falls: Patient states she has not had any accidents or falls.
Obstetrical History (If applicable): Patient had non complicated vaginal delivery.
Sexual History: Patient is actively participating in sexual activity with her husband. Patient states she has only had three male partners in her lifetime. Emotional Status (past and present): Patient states she has been experiencing some additional stress from work. Otherwise no complaints or history of complaints at this time. Mental Health Status (past and present): Patient states she does not have any history of mental health problems.
Verbal History Student Name: Date: Client Name: Age: _34_Sex: _F__Marital Status: Married
Race including Ethnic Affiliation: _Caucasian_Religion: Christian_
Current Occupation: Pharmacy technician_
Birthplace: Oklahomia City, OK
Chief Complaint: Headaches History of Present Illness or problem: Patient stating that headaches have been occurring more often and severity is worse. Patient states this began about a month and a half ago. Two to three a week per patient. Patient also has complaints of nausea, vomiting, neck tension, and photosensitivity. Past Medical History: Patient has a medical history of hypertension diagnosed in 2010. For which she takes an ACE Inhibitor for. Patient has also had a history of one vaginal birth with no complications. Childhood Illness: Patient denies any illnesses or diagnoses prior to 2010.
Immunizations: Patient states her immunizations are required to be up to date by her employer.
Allergies (past and present)
Food: ________None applicable ____
Medications: _ None applicable__
Environmental: __ None applicable ____ Current Medications including OTC: Lisinopril 20mg, Mirena
Hospitalizations/Serious Illness/Surgery, include year: Vaginal non complicated delivery 2009
Accidents/Falls: Patient states she has not had any accidents or falls.
Obstetrical History (If applicable): Patient had non complicated vaginal delivery.
Sexual History: Patient is actively participating in sexual activity with her husband. Patient states she has only had three male partners in her lifetime. Emotional Status (past and present): Patient states she has been experiencing some additional stress from work. Otherwise no complaints or history of complaints at this time. Mental Health Status (past and present): Patient states she does not have any history of mental health problems.