Health history: nursing

Topics: Medicine, Family, Health Pages: 5 (646 words) Published: March 24, 2014
Health History

Biographical Data

Name: JTBirthplace: Couderport, PA USA

Address: 34 Coneville Road Coudersport PA 16915 Gender: Female

Phone Number: 814-698-2425Marital status: Not married

Age: 18 Race: White

Birthdate: 8/29/1995ethnic 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 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...
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