Youngstown State University

Department of Nursing
NURS 2643 Health Assessment

HEALTH HISTORY DOCUMENTATION FORM

Interviewer: Daniel Macinga Date of Interview: 11/01/18

I. Biographical Data

A. Client’s Initials: CEC

B. Age: 22 Birth Date: 5/15/96 Birthplace: Unknown to patient

C. Sex: Female Marital Status: Single Race: Caucasian Ethnic Origin: German

D. Usual Occupation: Manager at Boardman Barnes & Noble, Scribe at Sharon Regional
Hospital

E. Present Occupation: Manager at Boardman Barnes & Noble, Scribe at Sharon Regional
Hospital

II. Source of Data: Patient

III. Reason for Seeking Care (Chief Complaint): Routine well-check

IV. Present Health (History of Present Illness):

In summary, this is a 22 year old female with no significant past medical history who presented
on 11/01/2018 for a routine well-check.

V. Past Health (Past History)

A. Childhood Illnesses:
Patient reports no childhood illnesses.

B. Childhood Immunizations:
Patient reports receiving Hepatitis B vaccine series, MMR vaccine series, and Varicella
vaccine.

C. Accidents or Injuries:
Patient reports broken nose at age 12. Was corrected by MD with no further
complications to date.
 D. Serious or Chronic Illnesses:
Patient reports no serious or chronic illnesses

E. Hospitalizations and Operations:

Patient reports no major operations or extended hospital stays.

F. Obstetric History (if applicable):

Patient reports first menses in 2014. She notes quarterly menses from 2014-present.

G. Adult Immunizations:
Patient reports all immunizations are up to date, as they were required prior to starting
job as a scribe in June, 2018.

H. Last Examination Dates:

December 23, 2017 – OB-GYN appointment

I. Allergies/Reactions:
Patient reports being allergic to latex and chocolate. Reports face and throat swelling,
syncope when exposed.

J. How Would You Describe Your Health?

Patient reports being within good health. Maintains routine vigorous activity,
throughout week. Eats a well-rounded diet. Maintains active social life while balancing
work and preparing for medical school.

VI. Medications (Name/Dosage/Dosage Times):

Birth control orally at 8pm daily and Valtrex as needed.

VII. Family History (include family tree):

Patient is adopted and does not know familial history

VIII. Social History, Culture, Religion, Education:

Patient is agnostic and is not affiliated with any specific religions. Patient has two associates
degrees and one bachelors degree in Biochemistry.

IX. Review of Systems

A. General Overall Health State:

Patient reports being in good health.
B. Skin:
Patient denies history of skin disease. Denies hyper/hypopigmentation, dysplastic nevi.
Denies pruritus, hematoma presence, skin rashes or lesions. Patient uses moisturizers
regularly following morning and evening showers.

C. Hair:
Patient reports no hair loss, hair brittleness, changes to hair texture. Patient denies
trichotillomania.

D. Nails:
Patient denies discoloration, changes in texture, shape, thickness, of nails.

E. Head:
Patient denies history of headache, vertigo, or injury to head. Reports no lumps or
masses. Denies history of surgery.

F. Eyes:
Patient denies difficulty seeing or blurred vision. Denies eye pain, redness, swelling,
excessive watering or tearing. Patient reports no history of injury or surgery on eyes.
Patient completes annual eye exams. Patient denies use of corrective lenses.

G. Ears:
Patient denies earache, pain, discharge, hearing impairment, tinnitus, otitis or vertigo.
Patient reports no loud noises in daily environment. Patient routinely cleans ears
following evening shower.

H. Nose and Sinuses:

Patient reports no history of discharge, sinus problems, obstruction, epistaxis, or allergy.
Colds 1-2 years, with mild symptoms. Patient reports fractured nose during high school
sports, treated by MD.

I. Mouth and Throat:

Patient denies pain, lesions, bleeding gums, toothache, dysphagia, or hoarseness.
Reports sore throat with rhinovirus. Patient visits dentist, dental hygienist annually.
Patient reports no dental surgery or use of corrective measures to teeth.

J. Neck:
Patient denies pain, lymphadenopathy, masses or lumps. Reports no history of surgery.

K. Breast:
Patient reports no lumps, masses, or lymphadenopathy. Patient routinely examines
breasts monthly and receives annual breast exam. Patient reports no tenderness,
discoloration, or pain in breasts.
L. Axilla
Patient denies tenderness, lumps, swelling, or rash.

M. Respiratory System:
Patient denies chest pain with breathing, wheezing, hemoptysis, or shortness of breath.
Patient reports no recent toxin or pollution exposure. Denies history of lung disease.

N. Cardiovascular System:
Patient denies history of angina, bradycardia/tachycardia. Patient denies routine cough,
peripheral edema, cyanosis, erythema. Patient reports no history of nocturia or dysuria.
Patient reports no known history of heart disease or familial history of diabetes,
hypertension, high cholesterol, obesity. Patient denies use of cardiac medication.
Patient reports alcohol use socially.

O. Peripheral Vascular System:

Patient reports no leg pain, skin changes, edema in periphery. Patient denies
lymphadenopathy. Patient reports no history of cigarette usage.

P. Gastrointestinal System:
Patient denies changes in appetite. Denies dysphagia, abdominal pain, or
nausea/vomiting. Patient reports no known intolerable foods to date. Patient reports
regular bowel movements following each meal x3 daily. Patient denies past history of
gastrointestinal disease.
Diet over previous 24 hours:
 Oatmeal with coffee (breakfast)
 Brown rice, steak, sautéed veggies, corn, salsa (lunch)
 Protein shake (snack)
 Grilled Italian chicken with brown rice (dinner)

Q. Urinary System:
Patient denies dysuria, polyuria, or oliguria. Denies change in color of urine. Reports no
history of kidney stones, UTI, kidney disease. Denies flank, groin, lower back pain.

R. Male or Female Genital System:

Patient denies sores, lesions, irritating or foul-smelling vaginal discharge. Uses birth
control. Patient reports no plans for pregnancy at this time. Denies STI incidence both
previous and current.

S. Sexual Health:
Patient reports satisfaction with sexual relationship with boyfriend. Uses protection
when engaging in sexual activity.
 T. Musculoskeletal System
Patient denies joint pain, stiffness, swelling, or limitation in daily life. Reports no muscle
pain or weakness. Patient reports no history of bone trauma or deformity.

U. Neurologic System:
Patient denies frequent or severe headaches, head injury, dizziness, vertigo, seizures, or
tremors. Reports no weakness, numbness, tingling, difficulty swallowing or speaking.
Reports no history of stroke, spinal cord injury, meningitis, or alcohol disorder.

V. Hematologic System:
Patient denies excessive bleeding of skin or mucous membranes, bruising, lymph node
swelling. Denies history of bleeding disorder or transfusions.

W. Endocrine System:
Patient reports no history of diabetes or polyuria, polydipsia, polyphagia. Denies
intolerance to heat or cold, recent change in skin pigmentation or texture, excessive
sweating. Reports normal appetite and weight relationship. Denies abnormal hair
distribution

X. Functional Assessment

A. Self-Esteem/Self-Concept:
Bachelor degree obtained.

B. Activity/Exercise:
Crossfit x4-5 days a week, with moderate aerobic activity x2-3 times a week.

C. Sleep/Rest:
Patient reports routinely 7 hours of sleep. Denies use of sleep aids. Routinely naps
during the day.

D. Nutrition/Elimination:
Patient reports regularly drinking 2 cups of coffee a day. Claims she had oatmeal with
coffee (breakfast), brown rice, steak, sautéed veggies, corn, salsa (lunch), protein shake
(snack), grilled Italian chicken with brown rice (dinner).

E. Interpersonal Relationships/Resources:
Patient claims she has a good support system with healthy relationships extending to
boyfriend, 4 living brothers, adopted mother, step-father, grandmother, and
grandfather still living, and many good friends.

F. Coping and Stress Management:

Patient graduated from college in December of this past year and is currently in gap year
for medical school. Took MCAT in June of current year. Reports engagement in physical
activity as major coping mechanism.
G. Personal Habits:
Patient last had alcohol on 10/27/18 while out with friends. Patient drank three beers
and two shots of whiskey. Patient denies drinking problems. Patient has never smoked
or used recreational drugs.

H. Environment/Hazards:
Patient lives alone in apartment complex with pet cat. Knows all surrounding neighbors
well. Feels safe in apartment. Patient reports working heat, water, electricity, and
amenities.

I. Occupational Health:
Patient works at cash register and as a hospital scribe. Patient states that they are on
their feet frequently throughout day. Patient does not use protective equipment or is
exposed to hazards, inhalants, or chemicals.