Health Assessment

Plantar reflex

Client Profile:
B.T. is a Chinese 42 years old male born in Singapore. Weight: 79kg, height 169cm. Married and lives with his wife, a son and daughter in a three room HDB flat. Highest level of education GCE ‘O’ level. Occupation taxi driver. Speaks and write in English and Chinese, speaks only Malay, Hokkien and Cantonese.

A. Review of Client’s Health Perception (Problems) Get shortness of breath after climbing more than 20 flights of stairs. Not exercising since birth of second child five years ago. Smoke 10 cigarettes daily for 15 years. States that he wants to start exercising but could not find time. Wants to quit smoking. Occasionally having neck and lower back aches due to driving long hours. Concern about aches getting progressively worse, it might affect his job.

B. Review of Past Health Status (including family history) Had childhood asthma, no attack since 12 years old. Chickenpox at age 16. High cholesterol level 4 years ago. Father had diabetes, hypertension, hyperlipidaemia and AMI. Mother had CA breast and hypertension. Unaware about grandparents medical history.

C. Immunisation Status BCG, diphtheria, pertussis, tetanus, poliomyelitis, mumps, measles, rubella, tuberculosis, Hepatitis B

D. Medication currently taken (including non prescriptive items) Lipitor 5mg daily

E. Known drug sensitivity and reactions No known drug allergy

F. Allergies Allergic to dust. Sneeze, running nose, itchy and watery eyes once expose to dusty environment

G. Developmental data Developmental level: Generativity vs Stagnation States that proud to be the father of two kids. Describes relationship with...
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