‘Youngstown State University | ep Department of Nursing NURSG 2643, HEALTH HISTORY DOCUMENTATION FORM Date of Interview: W/4/lv _ Interviewer: Jammie Gumbattist 1. Biographical Data: Client's Initials: JG. Age: 52 Birthdate: 8/1/1404 Birthplace: Yo nngstown, OF Sex: F Marital Status: mateledRace: (awaria Ethnic Origin: Tratan) folsihs Usual Occupation: homemaker a Present Occupation: school libeaopain M, Source of Data: ftom patunt hwerels IIL. Reason for Seeking Care (Chief Complaint): “or a physical exam”? a IV. Present Health (History of Present Ilness): “Tarn oreéalt a healthy indvidaat with Wnnicd health propre” V. Past Health (Past History) A. Childhood Illness / Immunizations: Hd che mi, y in HEART Uren pectuoie uae, MAMRS a6 Eyes ald VeRLGdLa shoe. ten, Golbod teructing step Apvcat Sarno Foam arg Sn! heh, gettin 4 nO MACE complicatiOne. LunMUMERtIons: ddEE Not know. Hane, PaEPOAWCLLES WHF age. polgaett 5, diphare,pacygge/ sesen ep AB i aman itch Sata Ue, ma Ube B. Accidents of Injuries: Wo" (qe ducidins in pose Tani pentdet, coecal var Reta aaa eta adeet ness Kahan set wo ag HR anvtin subrded with Hoe BOacdman, Dactoe wacnown kept fon Mtisenoe vation C. Serious of Chronic Illnesses: uo astinma, diabetes, bh. BA RG a dai Sn a Grdvac. Dotge nenowN fae Hail? STE FANE pasicd away. CuestnTly het aundepira= Hospitalizations and Operations 147, Clabes Ma Hearty gaat went Wide te TF EPpE magic, horde cay eet af pe ir i § —— “ Tis Ss Lee sping fan al, FU fe be (aba rate orth 7 si hese inten tian Meee yeuneatayal, Seen te , ny fanart ial csi i Byes pata Hharcel, G yeder 492 by be. th wettest Cece RIE Mons, Sera shy bine wees is isin We gi These Penance ‘PF yh! Tea Re ut? Go ety ition, Mae re ee tere Cath TIAL: OF done, tdregy em Adult Immunizations: We, prewmoccscl cacting, Ua tinvagocccal ducire os hisan agi ong vw GIGS tehdnas Unemawh. Recee Pore nps Me tal hatha ees eiga at Apa AVS Eg Atal er yometnt: Lat ia vice wat yen, eccetcee Me ah aaa, Meee, Wad Gqltpaeate tery Last. Examination Date: the most sant ie 40, clea Ram Ec 6. wor within aa Satis ceaaerh eco iar aetna Oe aake. Noster Rp een Slr gid Wil Also wo yeare “ago. Lab huoeing exam Allergies / Reactions: NO alleeguts 4p (004 on envtecrmental Aieyia te mad cto ‘enc ul ie (een eel 9 lf inyuy How would you describe your health? VI. Medications Dose Dosage Times 1 ¢ fantidepearcte any 2 ae daily E ‘Deysoud mediaeidy, inka Aut i ie E aaa or 4 5, (Saree rere aed ag. os ee 6 7 8 9 10.‘VIL. Family History (include family tree): (se attauied farnty sHe0) pa i fon: Faiied inthe niked Sats. She re 0 ptrowg, Catholic with, He aero tan Ree ent an atay eu Buduloe 3 RED in Spec THECOMmuNEaHe he. Reom Youngtsnen Stave Unweeritys which she Fécelued m4 9, IX. _ Review of Systems: A. General Overall Health State: Pusen! weigirt normal wth «© incecor o ge Ata Sk naalaisey feep chile, might Awe fa mF Mrcare. We Fah ipa, ntanany B. Skin: wo futery oF 9kin dicease 6h ws C724, protest; te hivee, NO pr : ethers In evict maus|sian rage Me UAE deainacs ae moirtuge’ Seattye geese ay Gah 1 SETA Me ten. sun chp drug was many hous @ AM VTHR peutstD , carive belay Bow, “sun datany the Summea winter le 4 HE fay abant, Ww) sinsrorer ea thy et Allway! AY THRSERE A C. Hair: Wo hale Voss o¢ feature changer, ing used voweres PLA Un aNGe KN EIIKD VE CyCTanhas D. Nails:ps unwrnaily fecaucne . Te har acy PU ae Ras OR dhdngey sn cnaye on ee. Ne nailt and We had thim oe Geaes, E. Head: Ne Teaawant ot sevene headache Ad aad suey ec ee , cop 9, 8 vert F. Byes: Sowuwhat didtuully with vurien , Lecetarcd Acuity ( Fapsigne Last tye ey i‘ Fecha wor glare. ag beng nl p04 agePan, dipfonte veda eceiy od MOSES: TE ERORES Ni eye, MONDE etry Now and that) QB glascome On tatanaces