Health History Documentation Form

Interviewer: Makayla Sims Date of Interview: 10/25/18

I. Biographical Data

A. Clients Initials: N.L.V

B. Age: 39 Birth Date: 12/28/78 Birthplace: Youngstown, Ohio

C. Sex: F Marital Status: Divorced Race:white Ethnic Origin: Italian

D. Usual Occupation: Unemployed

E. Present Occupation: Unemployed

II. Source of Data: Patient herself, who seems reliable

III. Reason for Seeking Care (Chief Complaint): Patient is coming in for an annual physical

IV. Present Health (History of Present Illness): Patient denies any kind of illness, and

claims to feel healthy at this present moment.

V. Past Health (Past History)

A. Childhood Illnesses: Patient denies any childhood illnesses besides Chicken

Pox and strep throat.

B. Childhood Immunizations: Patient claims to have received the flu shot, Tdap,

Hepatitis B, MMR, and Tetanus immunizations as a child. She says that she

does not recall the ages at which she received these immunizations.

C. Accidents or Injuries: Patient denies any auto accidents, fractures, penetrating

wounds, head injuries, or burns.

D. Serious or Chronic Illnesses: Patient denies any history of asthma, depression,

diabetes, hypertension, heart disease, human immunodeficiency virus,

infections, hepatitis, sickle-cell anemia, cancer, and seizure disorders.

 E. Hospitalizations and Operations: Patient denies any hospitalizations, but

claims to have had her tubes tied in march of 2005, at Saint Elizabeth hospital

in Youngstown Ohio. She claims to not recall the surgeon's name, and

describes her recovery as quick and easy.

F. Obstetric History: N.V claims to have had three pregnancies that all reached

full term. She has had two girls and one boy, and all three children are still

living. She claims all of her labor and deliveries have gone well, and she can

not recall the weight of each infant, but notes that all three babies were

healthy. The patient denies any preterm pregnancies, miscarriages, abortions,

or postpartum depression.

G. Adult Immunization: Patient denies any adult immunizations, besides the

occasional annual flu shot.

H. Last Examination Dates: Patient denies ever having a hearing examination,

vision test, ECG, chest x-ray film, mammogram, Pap test, stool occult test, or

serum cholesterol examination. The patient claims she does go to the dentist

every six months, her last dental exam being 4/18/18. The patient also claims

to be unsure of her last physical examination date, but guesses her last

physical examination was some time in 2015, where she was deemed health

and well.

I. Allergies/Reactions: Patient denies any know drug, food, or insect allergies.

J. How Would You Describe Your Health?: Patient describes her health as being

well kept.

VI. Medication (Name/Dosage/Dosage Times): Patient denies taking any kind of

medications, but does at times take two 325mg aspirin tablets for the occasional headache.
VII. Family History (Including family tree): Patient denies any family history of heart

disease, high blood pressure, diabetes, and alcohol or drug abuse.

VIII. Social History, Culture, Religion, Education: N.V claims to be a fulltime mom who is

very close to all of her children and speaks with them daily. She is a muslim and often helps

out at her church, and talks often with her church family. The patient claims her highest level

of education is high school.

IX. Review of Systems

A. General Overall Health State: Patient says she is 145, and has maintained this weight

since her 20s. Patient denies any fatigue, weakness, fever, malaise, chills, or night

sweats.

B. Skin: Patient denies any history skin disease, pigment or color change, excessive

dryness or moisture, pruritus, excessive bruising, rashes, or lesions.

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

Patient also claims to use a deep conditioning treatment on her hair once a week.

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

Patient also claims to moisturize hands daily, and to keep nails clean cut.

E. Head: Patient denies any unusually frequent or severe headaches, dizziness, recent

head injuries, or vertigo.

F. Eyes: Patient denies any difficulty with vision, eye pain, discharge, excessive tearing,

diplopia, cataracts, glaucoma, and claims to have no recollection of ever having an

eye exam.

G. Ears: Patient denies any earaches, history of ear infection, discharge, or tinnitus.

Patient also claims to clean her ears gently with a q-tip once every two weeks, and to

not be exposed to any harmful environmental noise.

H. Nose and Sinuses: Patient denies any frequent or severe colds, nasal discharge,

drainage, nasal congestion, sinus pain, nose bleeds, or change in sense of smell.

I. Mouth and Throat: Patient denies any frequent sore throat, mouth pain, bleeding

gums, toothache, lesions in mouth or on tongue, dysphagia, hoarseness, voice change,

tonsillectomy, or altered taste.

J. Neck: Patient denies any neck pain, limitation of motion, lumps or swelling, goiter,

and enlarged or tender nodes.

K. Breast: Patient denies any history of breast disease, surgery on the breast, lumps,

tenderness, pain, or nipple discharge. She claims to occasionally do a

self-examination of her breasts in the shower.

L. Axilla: Patient denies any tenderness, rash, lumps, or swelling.

M. Respiratory system: Patient denies any history of lung disease, wheezing, chest pain

when breathing, noisy breathing, shortness of breath, or hemoptysis.

N. Cardiovascular System: Patient denies any general chest pain, pressure, tightness,

fullness, palpitations, cyanosis, dyspnea, exertion, history of heart murmurs,

hypertension, nocturia, edema, coronary heart disease, or anemia.

O. Peripheral Vascular System: Patient denies any coldness, numbness, tingling, swelling

of the legs, discoloration of hands and feet, varicose veins, intermittent claudication,

or ulcers.

P. Gastrointestinal System: Patient denies any history of abdominal disease,

constipation, nausea, vomiting, diarrhea, abdominal pain, change in appetite or food

tolerance, heartburn, indigestion, pyrosis, pain associated with eating, rectal bleeding,

or change in bowel movement.

Q. Urinary System: Patient denies any history of urinary disease, abnormal urine

frequency or nocturia, dysuria, polyuria, oliguria, pain in flank, groin, or lower back,

hesitancy or straining during urination, or change in color or duration of urine.

R. Male or Female Genital System: Patient claims she got her first menstrual period at

the age of thirteen, and her last menstrual period was on 10/1/18-10/7/18. Patient

states that her cycle is normal, and denies any pre-menstrual pain, spotting, vaginal

itching, discharge, amenorrhea, menorrhagia, or menopause signs and symptoms.

S. Sexual Health: Patient claims she is not in a relationship involving intercours, and that

she is not aware of any contact with a partner who has any sexually transmitted

infections.

T. Musculoskeletal System: Patient denies any history of arthritis or gout, pain in joints,

stiffness in joints, swelling, noise with joint movement, limitation of motion, muscle

pain, cramps, back pain or history of disk disease, deformity, gait problems, problems

with coordinated activities, or weakness.

U. Neurological System: Patient denies any history of seizure disorders, stroke, fainting,

blackouts, tremors or paralysis, numbness, tingling, memory disorders, mood change,

depression, history of mental health dysfunction or hallucinations. Patient does report

some nervousness in high stress situations, and states that she copes with prayer.

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

membranes, excessive bruising, lymph node swelling, exposure to toxic agents, blood

transfusion and reactions.

W. Endocrine System: Patient denies any heat or cold intolerance, excessive sweating,

history of thyroid disease, change in skin pigmentation or texture, or need for

 hormone therapy. The patient also claims her relationship between appetite and

weight are normal.

X. Functional Assessment

A. Self-Esteem/Self-Concept: Patient claims her highest grade completed was twelfth,

and that she obtains enough money to support her lifestyle. She says she practises

islam, and believes her strength is compassion for others.

B. Activity/Exercise: Patient claims to be able to perform all tasks of daily living, and

denies use of any wheelchair or aid. She also claims to watch television for three

hours a day, and to do yoga for one hour a day. She says she has no particular method

of warm up for her practice.

C. Sleep/Rest: Patient claims to sleep around eight hours each night, and to spend around

1-2 hours napping during the day. She also denies use of any sleep aid.

D. Nutrition/Elimination: Patient says in the last 24 hours she has eaten bread, hummus,

water, grapefruit, chicken salad, and pasta. She claims this menu is typical for most

days, and she often uses grapes and nuts as snacks throughout the day. She says her

appetite is normal, and that she buys and prepares most food in her household. In

addition, the patient claims typically only her youngest daughter is present at

mealtime, she does not consume caffeine, has no allergies, has a bowel movement

once a day, and urinates every few hours.

E. Interpersonal Relationships/Resources: Patient would describe her role in the family

as the caretaker and heart of the family. She says she gets along more than well with

all her family and friends, and can always go to her father or aunts for any kind of

problem and support. She also claims to enjoy time alone, but also enjoy having all

her kids home together.

F. Coping and Stress Management: Patent claims she often stresses over her older

children in general, and often worries about them. She states she has no current stress,

or change in lifestyle, and that prayer and yoga help relieve any stress she might feel.

G. Personal Habits: Patient denies any smoking or drinking of any kind.

H. Environment/Hazards: Patient denies living alone, living in an unsafe area, or having

any hazards at home. She claims to have access to transport, adequate heat, and

utilities. She says that she wears her seatbelt, and does not travel out of the country.

I. Occupational Health: Patient claims to have not worked much throughout her life, and

to not have been exposed to any health hazards. Although she says she may have been

exposed to chemicals while getting her hair done.