H&P write up
Student Laboratory Guide Write-up: Comprehensive History
With your “patient” assuming the role of a client, conduct a comprehensive history.
History
Biographic Data
Date: 10/04/2013
Initials only: L.C.
Gender: M
Race: H
Date of Birth: 04/15/1972
Age: 42
Marital Status: married
Historian quality : Good
Occupation: Aircraft mechanic
Source of Data: Patient
Reason for Seeking Care/Presenting Problem:
Present Health Status Anemia Asthma Artery Disease Osteoarthritis Rheumatoid Bronchitis Cholecystitis Chronic Obstructive Pulmonary Arthritis Disease Cirrhosis Congestive Heart Failure Coronary Depression Diabetes, Type 1 Diabetes, Type 2 Disease Diverticular Emphysema Glaucoma Gout Hemophilia Hernia Hypertension Irritable Bowel Syndrome Multiple Osteoporosis Parkinson’s Psoriasis Sclerosis Disease Renal Failure Seizure Disorder Thyroid Disease Venous Insufficiency Vision Disturbance Other (describe):
Current medical conditions/Chronic illnesses (check all that apply)
Female:
Dysfunctional Fibrocystic Premenstrual Uterine Bleeding Breast Disease Syndrome
Male:
Prostate Disease
Current medications (include prescription, over-the-counter, herbs, and vitamins):
Name of Drug
Dosage/Frequency
Last Dose Taken
Reason for taking
Ventolin INH
2 puffs PRN
3 years ago
Asthma
Multivitamin
1 tab
10/04/2013
Supplement
Allergies to Medication/Foods/Medical Products/Other (e.g., latex, contrast, tape):
Allergic To
Type of Reaction
PCN
Hives,
With your “patient” assuming the role of a client, conduct a comprehensive history.
History
Biographic Data
Date: 10/04/2013
Initials only: L.C.
Gender: M
Race: H
Date of Birth: 04/15/1972
Age: 42
Marital Status: married
Historian quality : Good
Occupation: Aircraft mechanic
Source of Data: Patient
Reason for Seeking Care/Presenting Problem:
Present Health Status Anemia Asthma Artery Disease Osteoarthritis Rheumatoid Bronchitis Cholecystitis Chronic Obstructive Pulmonary Arthritis Disease Cirrhosis Congestive Heart Failure Coronary Depression Diabetes, Type 1 Diabetes, Type 2 Disease Diverticular Emphysema Glaucoma Gout Hemophilia Hernia Hypertension Irritable Bowel Syndrome Multiple Osteoporosis Parkinson’s Psoriasis Sclerosis Disease Renal Failure Seizure Disorder Thyroid Disease Venous Insufficiency Vision Disturbance Other (describe):
Current medical conditions/Chronic illnesses (check all that apply)
Female:
Dysfunctional Fibrocystic Premenstrual Uterine Bleeding Breast Disease Syndrome
Male:
Prostate Disease
Current medications (include prescription, over-the-counter, herbs, and vitamins):
Name of Drug
Dosage/Frequency
Last Dose Taken
Reason for taking
Ventolin INH
2 puffs PRN
3 years ago
Asthma
Multivitamin
1 tab
10/04/2013
Supplement
Allergies to Medication/Foods/Medical Products/Other (e.g., latex, contrast, tape):
Allergic To
Type of Reaction
PCN
Hives,