Sample Health History Paper
Health History
Biographical Data
Name: JT Birthplace: Couderport, PA USA
Address: 34 Coneville Road Coudersport PA 16915 Gender: Female
Phone Number: 814-698-2425 Marital status: Not married
Age: 18 Race: White
Birthdate: 8/29/1995 ethnic origin: German
Primary Language: English occupation: Full time Student
Social Security Number: xxx-xx-9301
Source: Patient herself, seems reliable
Reason for seeking care: Yearly checkup
History of Present Illness: nope
Past Health
General Health: "I am very healthy, and feel that I am healthy as a horse."
Childhood Illness: chicken pox ( 2000)
Accidents or Injuries: 1) chipped left ankle while playing football and I got tackled by a big guy. It hurt a lot. Went to Coudersport Charles Cole Hospital …show more content…
and they took x-rays and they told me I chipped the bone but it wasn't a full break. Had cast on for four weeks. (Incident occurred at age 12 (September 2006).
Serious or Chronic Illnesses: Pt states I have had no serious or chronic illness"
Hospitalizations: Pt states "I have never been hospitalized"
Operations: Pt states " I have been lucky to have never needed any operations"
Obstetric History: no children or pregnancies
Immunizations: All childhood immunizations up to date.
Last Examination Date: August 2013
Current Medications: Vitamin C , Midal for cramps
Allergies: Pt states I have no allergies that I know of
Family History:
Heart Disease: denies
HTN: not sure
Stroke: denies
Diabetes: Uncle on mom's side
Blood Disorders: denies
Breast Cancer: denies
Cancer: denies
Sickle cell: denies
Arthritis: maternal grandmother and paternal grandmother
Allergies: denies
Asthma: brother when he was younger but seemed to grow out of it
Obesity: paternal uncle and his children
Alcoholism: denies
Mental Illness: denies
Seizure Disorder: denies
Kidney Disease: denies
Tuberculosis: denies
Review of Systems:
General Overall Health State: Pt states " I think I am a very healthy person.
My family is overall extremely healthy so that helps. I do exercise but I feel that I should exercise more. I exercise approximately 2 or 3 times a week and try to go the gym for a couple hours a week. I don't eat the healthiest at college and the last couple of days I have been craving junk. Typically I try to eat veggies but all the veggies are gross in the cafeteria. I eat lots of grapes. I have hard time getting up in the mornings because I stay up late studying so I don't think I get enough sleep but throughout the day I don't feel that tired.
Skin: No changes in skin. Back of hands of get dried and cracked, rest of skin is soft. I always forget to put lotion on my hands.
Hair: Healthy hair with no hair loss. Texture is soft
Head:
Eyes: Stigmitism in right eye and I wear glasses or contacts. I have no idea what my vision is but I can see fine without my contacts and glasses so I know I don't have terrible vision
problems
Ears: Hearing is adequate and I've had any earaches. My mom suffers hearing loss and is deaf in one ear but we are not sure why. She woke up one morning and she could not hear out of her left ear and she went to doctors and they couldn't figure out why she could not hear
Nose and Sinuses: No sinus pain
Mouth and Throat: I get cold sores often. Ive had two cavities and I wear braces to line up my teeth
Neck: No neck pain
Breast: Denies pain
Respiratory System: No past history of lung disease , and no chest pain.
Cardiovascular:
Peripheral Vascular:
Gastrointestinal:
Urinary System: Drink 4-5 glasses of water daily
Female Genital System: Menarche at 13 years old ( December 25). Last menstrual period January 16 2014. Flow is slightly heavy
Sexual Health:
Musculoskeletal System:
Neurologic System:
Hematologic System:
Endocrine System:
Functional Assessment
Self-Esteem / Self-Concept:
Activity / Exercise
Sleep / Rest
Nutrition / Elimination:
Interpersonal Relationships / Resources:
Spiritual Resources:
Coping and Stress Management:
Personal Habits:
Environmental Hazards:
Intimate Partner Violence:
Occupational Health:
Perception of Own Health:
Biographical Data
Name: JT Birthplace: Couderport, PA USA
Address: 34 Coneville Road Coudersport PA 16915 Gender: Female
Phone Number: 814-698-2425 Marital status: Not married
Age: 18 Race: White
Birthdate: 8/29/1995 ethnic origin: German
Primary Language: English occupation: Full time Student
Social Security Number: xxx-xx-9301
Source: Patient herself, seems reliable
Reason for seeking care: Yearly checkup
History of Present Illness: nope
Past Health
General Health: "I am very healthy, and feel that I am healthy as a horse."
Childhood Illness: chicken pox ( 2000)
Accidents or Injuries: 1) chipped left ankle while playing football and I got tackled by a big guy. It hurt a lot. Went to Coudersport Charles Cole Hospital …show more content…
and they took x-rays and they told me I chipped the bone but it wasn't a full break. Had cast on for four weeks. (Incident occurred at age 12 (September 2006).
Serious or Chronic Illnesses: Pt states I have had no serious or chronic illness"
Hospitalizations: Pt states "I have never been hospitalized"
Operations: Pt states " I have been lucky to have never needed any operations"
Obstetric History: no children or pregnancies
Immunizations: All childhood immunizations up to date.
Last Examination Date: August 2013
Current Medications: Vitamin C , Midal for cramps
Allergies: Pt states I have no allergies that I know of
Family History:
Heart Disease: denies
HTN: not sure
Stroke: denies
Diabetes: Uncle on mom's side
Blood Disorders: denies
Breast Cancer: denies
Cancer: denies
Sickle cell: denies
Arthritis: maternal grandmother and paternal grandmother
Allergies: denies
Asthma: brother when he was younger but seemed to grow out of it
Obesity: paternal uncle and his children
Alcoholism: denies
Mental Illness: denies
Seizure Disorder: denies
Kidney Disease: denies
Tuberculosis: denies
Review of Systems:
General Overall Health State: Pt states " I think I am a very healthy person.
My family is overall extremely healthy so that helps. I do exercise but I feel that I should exercise more. I exercise approximately 2 or 3 times a week and try to go the gym for a couple hours a week. I don't eat the healthiest at college and the last couple of days I have been craving junk. Typically I try to eat veggies but all the veggies are gross in the cafeteria. I eat lots of grapes. I have hard time getting up in the mornings because I stay up late studying so I don't think I get enough sleep but throughout the day I don't feel that tired.
Skin: No changes in skin. Back of hands of get dried and cracked, rest of skin is soft. I always forget to put lotion on my hands.
Hair: Healthy hair with no hair loss. Texture is soft
Head:
Eyes: Stigmitism in right eye and I wear glasses or contacts. I have no idea what my vision is but I can see fine without my contacts and glasses so I know I don't have terrible vision
problems
Ears: Hearing is adequate and I've had any earaches. My mom suffers hearing loss and is deaf in one ear but we are not sure why. She woke up one morning and she could not hear out of her left ear and she went to doctors and they couldn't figure out why she could not hear
Nose and Sinuses: No sinus pain
Mouth and Throat: I get cold sores often. Ive had two cavities and I wear braces to line up my teeth
Neck: No neck pain
Breast: Denies pain
Respiratory System: No past history of lung disease , and no chest pain.
Cardiovascular:
Peripheral Vascular:
Gastrointestinal:
Urinary System: Drink 4-5 glasses of water daily
Female Genital System: Menarche at 13 years old ( December 25). Last menstrual period January 16 2014. Flow is slightly heavy
Sexual Health:
Musculoskeletal System:
Neurologic System:
Hematologic System:
Endocrine System:
Functional Assessment
Self-Esteem / Self-Concept:
Activity / Exercise
Sleep / Rest
Nutrition / Elimination:
Interpersonal Relationships / Resources:
Spiritual Resources:
Coping and Stress Management:
Personal Habits:
Environmental Hazards:
Intimate Partner Violence:
Occupational Health:
Perception of Own Health: