Health history assignment

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Complete Health History Assignment
STUDENT NAME:

Biographical Information






DOB: 10/06/1987
Gender: female
Race: Caucasian
Ethnicity: French
Additional (Insurance information)

Source and Reliability



Where does the information come from
What indicators of reliability are there

Reason for Seeking Care


CC: headache

History of Present Illness (HPI)


Throbbing for the past two hours, can feel pulse in temples, 4 on a scale of 1-10, started while in the student center checking her mailbox; other symptoms: thirsty; has not taken any medications

Past Medical History











General State of Health: good
Past illnesses: none
Chronic Illnesses: minor scoliosis (no pain or limitations)
Injuries and treatments: broken toe in first grade (had crutches); visited a chiropractor Hospitalizations: none
Surgeries: wisdom teeth removed (Dec. 2002)
Active/Chronic Problems: sports-induced asthma; no limitations; not being treated Allergies
o Seasonal; no food allergies
o Drugs – See medication history below: had a drug reaction to an unknown asthma medicine at age 8
Substance use/abuse
o No tobacco use. Drinks wine ~once/month
o Recreational drugs: none

1





Exercise: running once every 2 weeks; trying to exercise more regularly; does Yoga once every 2 weeks
Nutrition: “neither overly unhealthy nor healthy”
Sleep Pattern: tries for 8 hours every night; a short nap every couple days

Medication History











Current medications: none
Vitamins: no, feels she should
Herbal remedies/health supplements: none
Past medication: Albuterol, d/c’d 2 years ago
o Dose: 1 to 2 puffs as needed
o Reason for taking: asthma
o Reason for d/c: no need for it;
Past medication: Benzaclyn d/c’d six months ago
o Dose: topical
o Reason for taking: acne
o Reason for d/c: trying to find something that would work better Past medication: another asthma medication (does not recall what) o Dose: 1 puff a day in season
o Reason for taking: asthma
o Reason for d/c: rash
Allergies/ADR’s:
o unknown asthma drug; rash at age 8. No treatment other than stopping the drug.

Health Maintenance










Immunizations: “up to date”
Frequency of physicals or routine care: annually
Gynecological exams – Frequency and last: none
Eye: every other year
Cholesterol: whenever she donates blood; 197-203
Self breast and testicular exams: no
Seat belts, bike helmets: yes, no
Efforts to change: trying to exercise more
Diets:no particular

Environmental Health








Occupation: student and Resident Assistant; after-school care supervisor Nature of Work: 20 hours a week, variety of tasks, supervision, rule enforcement; supervise small children
Work setting – sun, office building; residence hall; classroom, cafeteria, playground Exposure to hazardous materials and loud noises: no
Hobbies: reading, spending time with people, cross stitching Work related symptoms: occasional headaches; no treatment
Travel history: UK, Caribbean, throughout USA

Family History (Genogram or list)




Health status (living, dead, ill): past 2 generations still living, except for an uncle Diseases: maternal grandparents diabetes, mother skin cancer, paternal grandmother breast cancer, several high cholesterol, high BP

Hereditary and environmental factors: alcohol abuse

Psychosocial and Spiritual History










“Tell me about yourself”: average girl, enjoy life, not suicidal, moderate amount of stress Upbringing: raised in a 2-parent home in a small town with 3 siblings Marital status, roommates: single, no longer has a roommate

Support network, friends: good
Perceptions of healthcare: beneficial, especially if covered by insurance Perceptions of and satisfaction with life: it’s good, she likes her life How has illness impacted life: creates the occasional discomfort Religious beliefs,...
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