‘Youngstown State University Department of Nursing NURSG 2643, HEALTH HISTORY DOCUMENTATION FORM. Date of Interview Interviewer: I. Biographical Data: Client's Initials:_HAG Age: 19 _ Birth date: 01/29/1996 _ Birthplace:Northside Hospital, Youngstown, Ohio ish Sex: F Marital Status: Single Race: White Ethnic Origin: !t Usual Occupation: College student Present Occupation: College student IL. Source of Data: Patient interview on 11/05/16 IIL. Reason for Seeking Care (Chief Complaint): P ferview on 11/05/16 IV. Present Health (History of Present Illness): Patient states, “I am healthy and don't currently have any issues” V. Past Health (Past History): A. Childhood Illness / Immunizations Childhood illnesses include strep throat, stomach flu, and bronchitis. No measles, mumps, rubella, chicken pox, pertussis, rheumatic fever, TB. Patient reports immunizations as “up to date” despite being unsure of which ones excluding: MMR, meningitis, and tetanus which are up to date, Patient has never been tested for TB or had a flu shot. B. Accidents or Injuries: No broken or fractured bones current or in past. Patient received 4 stitches on palmar surface of left hand after an accidental cut while opening a can. incident occurred on 10/11/2016. Treatment followed in St. Elizabeth Boardman ER on 10/11/2016. Wound healed with no reinjury, reopening, exudate, or infection, C._ Serious of Chronic Ilinesses Devoid of chronic disease except seasonal allergies. Allergies exacerbated by presence of pollen, especially during spring, summer, and fall. Patient takes 1 OTC Allegra D 24 hour 180mg tablet per day during periods of exacerbated symptoms.D Hospitalizations and Operations: Dual adnoidectomy 10/2004 at Southwoods Surgical Hospital Boardman; physician unknown. Dual tonsilectomy 06/2009 at Southwoods Surgical Hospital; physician unknown. Spinal fusion correct- ing severe scoiosis 04/08/2011 at Akron Children’s Hospital, Akron, Ohio with Dr. Adamczyk. Removal of 4 wisdom teeth 08/2014 by Dr. Bucci. All surgeries successful with no complications. E. Obstetric History No current or past history of pregnancy. Patient visits gynecologist (Dr. Smith) yearly. No sexual activity. Oral contraceptives taken upon waking each day (1 tablet of Minastrin) F. Adult Immunizations Tetanus shot on 10/11/2016 during ER visit from cut on left hand. Additional immunizations not present, G.Last Examination Date Multiple back X-Rays on various dates for scoliosis diagnosis, preoperative, and postoperative assessment. Chest X-Ray in 2010 for bronchitis. Last complete physical exam 07/2014 for high school cross country. No issues noted during exam; patient had no complaints, and examiner discovered no abnormalities. Last yearly optometrist visit 07/2016; 20/20 vision noted in both eyes despite patient feeling slight nearsightedness. No prescription for contacts or glasses. Hearing not regularly checked; unsure of last hearing test. H Allergies / Reactions: Allergies to pollen. No allergies or adverse reactions to food, of vitamins, OTC, prescription, herbal, or supplimental medications. How would you describe your health? "Overall good health, but | could use more exercise and sleep, and I could eat more balanced meals” VI. Medications Dose Dosage Times 1: Minastrin tablet Morning 2: Allegra D 24 hour 1x180mg tablet Morning 1uprofen 1x250mg tablet Asneeded 4: Tylenol 1x500mg tablet Asneeded laproxen Unsure Asneeded Patient takes none of the following: prescription medications not mentioned, allergy medications not mentioned, NSAIDs not mentioned, contraceptives not mentioned, herbal supplements, vitamins, aspirin, antacids, street drugs, and laxatives.VIL. Family History (include family tree): History of high cholesterol on father’s side. History of hypertension and diabetes on mother’s side. VIILSocial History, Culture, Religion, Education: Patient was born and raised in Boardman, Ohio. Catholic religion concurrent with that of her fami- Iy's. Patient is high school graduate working towards a pre-medical bachellor’s degree in Biology from Youngstown State University. IX.Review of Systems: A. General Overall Health State No fever, weakness, alaise, fatigue, nightsweats. Current weight is normal for patient and does not fluctuate considerably. sins genet pale and patient experiences sunbum easly. No history of skin disease including, eczema, psoriasis, hives. No pigment change in skin anywhere on body. No presence of moles. No excessive dryness or moistness. No excessive bruising or rashes. No lesions. Sunscreen worn only during summer months. Sunlight exposure ranges from all day in summer to 30-60 minutes during the winter. C. Hair: No hair loss or change in texture. Hair highlighted approximately every six months. Natural color is brown. D. Nails No change in shape, color, or brittleness. No history of ingrown toenails or fingernails or clubbing, EW error ne eter eer seen ag a ene er F. Eyes: Eyes both same color eyes have always been brown, 20/20 vision in both eyes, no dificult seeing near objects, but far objects sometimes appear blurry. No contacts or glasses worn currently or in the past. No pain in eyes, diplopia, watering, discharge, glaucoma, cataracts, blind spots. Last vision screening was 07/2016.