Youngstown State University

Department of Nursing
NURS 2643 Health Assessment

HEALTH HISTORY DOCUMENTATION FORM

Interviewer: Elizabeth Roux Date of Interview: 11/2/17

I. Biographical Data:
A. Client’s Initials: J. A. W.

B. Age: 31 Birth Date: 2/16/86 Birthplace: Mahoning County, OH.

C. Sex: Male Marital Status: Single Race: Caucasian Ethnic Origin: Italian

D. Usual Occupation: Personal Trainer

E. Present Occupation: Personal Trainer

II. Source of Data: Jack A. Wilkins, patient

III. Reason for Seeking Care (Chief Complaint): Physical examination

IV. Present Health (History of Present Illness): Patient denies having any present health issues or
illnesses.

V. Past Health (Past History):

A. Childhood Illnesses: Patient states that he had the chicken pox and strep throat as a
child. No measles, no mumps, no rublella, no pertussis, no rheumatic fever, no scarlet
fever, no poliomyelitis.

B. Childhood Immunizations: Patient received childhood immunizations including

measles/mumps/rubella, hepatitis A and B, TDAP. Patient received influenza vaccine
annually.

C. Accidents or Injuries: Patient denies any accidents/injuries. No head injuries or

fractures.
 D. Serious or Chronic Illnesses: Pateint denies having had any serious/chronic illnesses.
Patient denies diabetes, hypertension, heart disease, HIV infection, sickle cell anemia,
cancer, seizure disorders or hepatitis.

E. Hospitalizations and Operations: Pateint denies having had any long-term hospital stays.
Patient was in the emergency room at St. Elizabeth’s Boardman in February of 2015 for
8 hours for a stomach virus. Patient was given fluids and fully recovered within 2 days.
Patient received inguinal hernia repair at Salem community hospital in 2006. Patient
states the recovery was easy and he was up and running the next day. Patient received
LASIK eye surgery in 2009, in Canton, OH. Patient states the surgery was “easy” and he
was up and running a few hours post-op. Patient does not remember doctor’s names for
any of the above listed procedures/hospital stays. All exact dates unknown.

F. Obstetric History (if applicable): N/A for male patient.

G. Adult Immunizations: Patient is unsure of vaccinations of MMR, polio, dyptheria,

pertussis, tetanis, vericella, Hepatitis A and B, pneumococcal. Unsure of date of last date
of TB test. Patient receives flu vaccine annually.

H. Last Examination Dates: Patient received last physical exam in April 2017, last dental
exam was in June 2017, last vision screening was August 2017, last hearing screening
was April 2017, last ECG was in February of 2015 when he was hospitalized, last chest x-
ray was February 2015. Serum cholesterol was last taken in 2016. All exact dates
unknown.

I. Allergies/Reactions: Patient denies having any allergies.

J. How Would You Describe Your Health? Patient states he feels his overall health is
“excellent.” Patient states he feels “great” on a daily basis.

VI. Medications (Name/Dosage/Dosage Times): Patient denies taking any perscribed medications;
Patient takes a daily OTC allergy medication once a day, for the past year, with no side effects.
VII. Family History (include family tree):
Patient’s mother is deceased; died at age 51 of Acute Meyloid Leukemia. Patient has a living
father, age 72, current health problems include diabetes, and had a stroke in 2017. Patient has
no siblings. Grandparents are all deceased and listed on family tree; diseases included on family
tree are heart failure, stroke, and dimensia.

VIII. Social History, Culture, Religion, Education:

Patient enjoys exercise, including weight lifting and running. Patient rarely drinks alcohol, maybe
once or twice a year. Patient’s culture is Italian, patient states it is not a big part of his life.
Patient was raised in the United States. Patient’s religion is Christian, he attends church on a
weekly basis and is involved in his church. Patient graduated high school from Columbiana High
School in 2004. Highest education level for patient is college graduate from Youngstown State
University in 2016.

IX. Review of Systems:

A. General Overall Health State: Patient states that he is in “great” health. Not overweight,
no significant weight gain or loss, no pain or discomfort, no fatigue, weakness, malaise,
fever, chills, or night sweats.

B. Skin: Patient denies having any history of skin disease (eczema, hives or psoriasis) or any
pigment/color change, or change in moles (nevi), no excessive moisture or dryness
(pruitis), no excessive bruising, rash or lesion. Patient has one medium sized tattoo over
the left side of his chest. Patient states he doesn’t get too much sun exposure, patient
denies using SPF when exposed to the sun.

C. Hair: Patient denies any recent hair loss or change in texture.

D. Nails: Patient denies any change of shape, color, or brittleness.

E. Head: Patient denies any chronic or severe headaches, head injury, dizzieness, syncope,
or vertigo.
F. Eyes: Patient denies any difficulty with vision, eye pain, blind spots, diplopia, redness or
swelling, watering or discharge, glaucoma. Patient states that at last vision screening,
Dr. told him he is beginning to get cataracts. Patient denies wearing glasses or contacts,
received LASIK eye surgery in 2009. Last vision exam was August 2017. Exact date
unknown. Glaucoma was checked and patient had none. No ways to cope with vision
loss because vision loss is not present.

G. Ears: Patient denies earaches, infections, discharge, tinnitus or vertigo. Patient denies
any hearing loss. No exposure to environmental noise. Cleans ears daily with a Q-tip
after showering.

H. Nose and Sinuses: Patient denies any discharge, frequent/severe colds, sinus pain, nasal
obstructions, nosebleeds. Patient has seasonal allergies; denies hay fever, and change in
smell. No abnormal discharge.

I. Mouth and Throat: Patient denies any mouth pain, frequent sore throat, bleeding gums,
toothache, lesions in mouth/tongue, dysphagia, hoarseness/voice change or altered
taste. Patient still has tonsils, no tonsillectomy. Patient brushes teeth twice a day,
flosses once a day, last dental checkup was June 2017. Exact date unknown. No
prosthesis usage.

J. Neck: Patient denies any pain, patient has full ROM, denies lumps, swelling,
enlarged/tender lymph nodes, goiter. Neck appears normal and midline

K. Breast: Patient denies currently having or previously having any problems with breasts.
No gynocomastia noted. Does not perform self breast exam.

L. Axilla: Patient denies having any lumps, swelling, or rash in axilla. No problems in past
were stated.

M. Respiratory System: Patient states no history of any lung disease (asthma, emphysema,
bronchitis, pneumonia, or TB), denies chest pain with breathing, wheezing or noisy
breathing. Denies shortnesss of breath, cough sputum, hemoptysis, toxin or pollution
exposure. Patient states last chest x-ray and TB test were done in 2015.
N. Cardiovascular System: Patient denies chest pain, pressure, tightness or fullness; denies
palpitations, cyanosis, dyspnea on exertion, orthopnea, nocturia, edema. Denies history
of heart murmurs, hypertension, coronary artery disease, or anemia.

O. Peripheral Vascular System: Patient denies any coldness, numbness, tingling, or swelling
of the legs, denies discoloration in hands or feet; denies varicose veins, intermittent
claudictaion, thrombophlebitis, ulcers. Patients work involves long-term standing,
patient crosses legs at knee while sitting, and does not wear support hose.

P. Gastrointestinal System: Patient states normal appetite, eats around 5-6 times a day.
Patient denies any food intolerance, dyphagia, heartburn, indigestion, pain associated
with eating, or pyrosis. Patient denies any nausea or vomiting, vomiting blood, history of
abdomial disease (ulcer, liver, galbladder, jaundice, cholitis). Patient still has appendix.
Patient has normal flatulence, has bowel movements 3-4 times per day. Patient denies
any recent change in stool, stool is normal (solid, brown, formed) and easy to pass.
Patient denies constipation and diarrhea, black stools, rectal bleeding or rectal
conditions. Patient denies use of antacids and laxatives.

Q. Urinary System: Patient states frequency to urinate is 1x per hour, denies noturia,
dysura, polyuria, oliguria. Denies hesitancy or straining, narrowed stream. Urine color is
mostly clear, with a hint of yellow, patient denies cloudiness or presence of hematuria.
Patient denies incontinence, history of any urinary disease. Patient denies flank pain,
grouin pain, suprapubic region or low back pain. Patient denies any UTI history.

R. Male or Female Genital System: Patient denies any penis or testicular pain, denies
presence of sores or lesions, penile discharge, lumps. Patient had history of inguinal
hernia in the past, but was fixed surgically in 2006. Patient performs testicular self-
examination once every few months.

S. Sexual Health: Patient is in a relationship involving intercorse. Patient is in a

monogamous relationship with only one partner. Patient states that the aspects of sex
are satisfactory. Condoms are used routinely. Patient denies changes in erection or
ejaculation. Patient states that contraceptives are used and they are satisfactory. Patient
is not in contact, and has never been in contact with partner with a history of any STDs.

T. Musculoskeletal System: Patient denies any history of arthritis or gout. Patient states
that he has no pain in the joints but does have stiffness in his joints, mainly his hips.
 Patient denies any swelling in the joints, patient has no visible deformities or limitation
of motion. Patient states his knees crack occasionally with movement. Patient denies
any muscle pain, cramps, or weakness. Patient denies any problems with gait, or
problems with coordinated activities. Patient denies any back pain, stiffness, limitation
motion. Patient recalls a herniated disk in 2009. Patient increased mobility to treat and
changed his workout techniques to prevent future injury.

U. Neurologic System: Patient denies any history of seizure disorders, stroke, fainting, or
blackouts. No coordination, tic or tremor, or paralysis noted. Patient denies numbness
or tingling in the extremities. Patient denies any recent or present memory disorders,
denies any nervousness, mood change, or depression. Patient denies any history of
mental health dysfunction or hallucinations.

V. Hematologic System: Patient denies any tendency of bleeding of skin or mucous

membranes, denies excessive bruising. Patient deneis any lymph node swelling,
exposure to toxic agents or radiation. Patient has never had a blood transfusion.

W. Endocrine System: Patient has no history of diabetes or diabetic symptoms, although it

is present in the paternal side of his family. Denies history of thyroid disease,
intolerance to heat or cold, change in skin pigmentation or texture. Denies excessive
sweating. Patient states his relationship to appetite and weight are normal, patient
doesn’t gain or lose weight excessively with normal appetite. Patient denies abnormal
hair distribution, nervousness, tremors, or need for hormone therapy.

X. Functional Assessment:
A. Self-Esteem/Self-Concept: Patient has earned a Bachelor’s degree in Nutrition/Public
Health. Patient states his financial status is middle class, and has an adequate income.
Patient states he is a devout Christian and has many personal strengths including
honesty and dedication.

B. Activity/Exercise: Patient states a typical day includes “Waking up and making breakfast,
praying for about ten minutes, getting cleaned up, starts work at 5:00 AM, works out
 during lunch break, and is usually finished with work around 5:30-6:00 PM” Patient can
do ADLs independently. Patient states he enjoys reading and going out with his
girlfriend. Patient states his exercise pattern includes high intensity, moderate volume
weight lifting, 5x per week for an hour. Patient typically warms up for 10 minutes with
functional mobility movement.

C. Sleep/Rest: Patient states he typically gets 4-5 hours of sleep per night, never takes
daytime naps, and doesn’t rely on sleep aids.

D. Nutrition/Elimination: Patient recalls past 24 hours of food/beverage intake “For

breakfast I had eggs, oatmeal, and toast with a cup of coffee and around 20 oz. of water.
After my workout, I had a protein shake and banana. At 11AM, I had another cup of
coffee. For lunch I had chicken breast, rice and vegetables. Around 3 PM, I ate chicken
breast, rice and vegetables again. At 6 PM I ate dinner, which included a hamburger
patty, a sweet potato and a large carrot. I ate again at 9 PM, I had a piece of chicken
bacon and eggs. Throughout the day I drank a total of 2 gallons of water.” Patient states
for current eating habits/appetite “I eat very healthy and I’m always hungry.” Patient
states that he purchases his food and prepares it for himself. He states that his finances
are adequate for food, and that he and his girlfriend are present for mealtimes. Patient
denies any food intolerance or allergy. Patient states he has 2 cups of coffee per day.
Patient states his bowel movements and urination pattern is normal, he has no issues
with mobility, continence or use of laxatives.

E. Interpersonal Relationships/Resources: Patient describes his role in the family as “the

man in charge.” Patient states he gets along great with his family, friends and co-
workers. Patient states he has many people he could go to for a personal problem, but
mainly his girlfriend. Patient states he spends an adequate amount of time with his
girlfriend, family, and at work. Patient states that his time spent alone is pleasurable and
relaxing.

F. Coping and Stress Management: Patient states he doesn’t have too much stress,
occasionally has some stress due to work. Patient states he has no current stress.
Patient says he works out when he is very stressed, and states that it is very helpful.

G. Personal Habits: Patient denies smoking cigarettes, or doing street drugs. Patient rarely
drinks alcohol, maybe once a year.

H. Environment/Hazards: Patient lives with current girlfriend in a condo association and

has neighbors. The area he lives is safe, and has adequate heat and utilities. Patient
owns car, and is moderately involved in his community. Patient denies any hazards at
 work, in the home. Patient always uses seatbelt while driving. Patient denies ever
traveling to other countries, or having spent time in the military.

I. Occupational Health: Patient describes job as “health and wellness coach.” Patient
denies ever working with a health hazard. Patient’s occupation does not require any
protective equipment.