Youngstown State University Department of Nursing NURSG 2643 HEALTH HISTORY DOCUMENTATION FORM Date of Interview: 5.2016 LaeHenes RRR I, Biographical Data: (Client's Initials: B.C. Age: 36 Birth date: 5-3-1980 Birthplace: La Paz, Bolivia Sex: Male Marital Status: Married Race: Hispanic Ethnic Origin: Bolivian Usual Occupation: Software Developer Present Occupation: Software Developer IL, Source of Data: Client ~B.« IIL. Reason for Seeking Care (Chief Complaint): For a physical exam for employment IV. Present Health (History of Present Illness): B.C. has been diagnosed with Type 2 Diabetes since age 21's omuols it with diet and medieatpn. Had a physical exam by family doctor in lune of 2016. His AIC level was 5.5(Everythiip else appeared typical for someoue his age. B.C. had a prostate exam in November 2015 and prostate was not enlarged. B.C. does not suffer from hypertension or high cholesterol. He does not have any allergies to food, environment or medication. B.C. works out on te elliptical or treadmill 4 days a week for 30 inate periods. V. Past Health (Pact History): L ‘A. Childhood Illness / Immunizations: Client denies having measles, mumps, rubella as1a a child, Was vaccinated as a baby. Client had chicken pox had at 12 years old. Beri hhaving strep throat or fheumatic fever. Denies having scarlet fever croup or whooping ‘cough. Has had the Hepatitis B vaccination series in the last 10 years, TDAP (Tetanus, Diphtheria, Pertussis) inthe past yer. Client was negative for TD when tested 8 years ‘ago. Client had flu shot in October 2016. v B. Accidents or Injuries: Client denies ever having any serious accidents or injuries, ias never been ina car accident that resulted in injury. Has never had a sport injury. Has never had stitches or an open wound. C. Serious of Chronic Illnesses: Client has becn diagnosed with type 2 diabetes since age 21 which he controls with diet tnd medication “Client denies having hypertension, depression, high cholesterol, heart disease, lung disease, asthma, sickle cell anemia, ‘cancer, seizures, and hepatitis. D. Hospitalizations and Operations: flospitalized at Miami Valley Hespital in }) Dayton, OF for high blood sugar at age 21 in 2001. Was in the hospital for 3 days. Was ‘kept there until blood sugar was under control. Doctor unknown. Recovered well and now controls diabetes with diet and medication E Obstetric History: Not Applicable F. ‘Adult Immunizations: Has been immunized for measles, mumps, rubella, nut > diphtheria, petussis-tetanus, varicella, and hepatitis B series inthe past 10 years and \* SF \y received the influenza vaccine. Also had a negative TB skin test in the past 5 years Ce (negative for TB), G. Last Examination Date: Last physical exam was in June of 2016 by family doctor ~ ,,~ Dr. Walter Passarello, Had blood work done to check AIC. AIC was in normal range 2 1155 load pemie was check und was 22/78 aa dental exam was May 216. [No cavities or abnormalities were found. Last eye exam was July 2015. No vision changes reported. HL Allegis / Reasons: Cet denies ving any allergist fod environment or mization. rd How would you describe your health? Client reports health is good but would like to lose[30 to 40 pounds to prevent any more health complications. y VI. Medications Dose Dosage Times qe ¢ 9. Metformin 2 Pills Twice a Day / Morning and Night yw joe 4. ei Sie Dt AE ne a \' “a ‘Muki-vitamin Once a Day / Morning ‘L, Family History (include family tree): Family history shows strong history of type 2 diabetes. See attached family tree. IIL, Sosial Hietory, Culture Religion, Education: “tent was bom in Bolivia but ‘moved to the United States at age 1. His Hispanic culture is very important to him and speaks Spanish with his family at home and believes in keeping cetsn holiday and food traditions alive and in practice in his home. Client has no strong religious beliefs but wes raised Catholic as « child. Client hasa bachelor’s degree in Computer Science and ‘Management Information Systems from the University of Dayton. He graduated in 2005. IX. Review of Systems: ‘A. General Overall Health State: Client has type 2 diabetes and is 30-40 pounds ‘overweight but besides that is in good health. Has had no recent weight gain or loss. Denies having any fatigue, malaise, fever, cold-like symptoms, chills, flu-like ‘symptoms, night sweats. Does not have hypertension or high cholesterol. Denies having, any heart palpitations or breathing issves. B. Skin: No history of skin disease (eczema, psoriasis, hives), pigment or color change, change in moles, excessive dryness or moisture, pruritus, excessive bruising,