Example of a Health History Report
Essay title: Example of a Health History Report
Health History
1. Biographical Data
Date: 10/03/05
Examiner:
Name:
Phone:
Address:
Birth date:
Birth place:
Age: 19
Sex: M
Marital Status: Single
Occupation: Student
Race/ethnic origin: Caucasian
Employer: N/A
Health Insurance: None
2. Source and Reliability: Client himself, Seems reliable
3. Reason for Seeking Care: “Nausea, Upset stomach” Getting in the way of patients normal activity. Patient has had pain for up to 3 days now.
4. Present Health or History of Present Illness: Notices it more when he eats something. Noticed it first when he just got done eating, about 3 days ago. Not eating makes is better. And sleeping makes the patient feel better.
The severity of the pain on a scale of 1-10, patient rated it a 7.
Pain exists in the stomach, does not spread just hurts in the stomach. Pain has stayed the same for 3 days.
First noticed it after lunch 3 days ago. Patient has pain all the time but it gets worse after the patient eats.
Patient thinks this may be an ulcer of some kind.
5. Past Health:
General Health: Good
Childhood Illnesses: Chronic Bronchitis
Severe Chicken Pox
Accidents or Injuries: None
Serious or Chronic Illnesses: Bronchitis
Hospitalizations: Petersburg (Grant Memorial) Pectus Repair Surgery. Patient not sure of exact date but knows it was when he was in fifth grade.
(Garrett Memorial) Severe Stomach Flu. October 3, 1997
Operations: Pectus Repair Surgery
Obstetric History: None
Gravida: None
Preterm
(# Pregnancies)
(# Term Pregnancies)
(# Preterm Pregnancies)
Ab/incomplete
Children Living
(# Abortions/Miscarriages)
Course of Pregnancy
Immunizations: Hep B, Meningitis, MMR, Flu, Tetanus.
Last examination date: 09/26/05. Was told that he had severe depression. Patient was put on medication for depression.
Allergies: None
Reaction: None
Current Medications: Paxil, Prevacid.
6. Family History
Specify:
Heart disease
High Blood Pressure X
Stroke
Diabetes X
Blood Disorders
Breast Cancer X
Cancer(Other)
Sickle cell
Arthritis X
Allergies X
Asthma X
Obesity
Alcoholism
Mental Illness X
Seizure disorder
Kidney Disease
Tuberculosis
7. Review of Systems
General Overall Health State: Present weight is162, patient recently lost weight, not experiencing fatigue, weakness, fever, chills, sweats or night sweats.
Skin: mole removed (the color changed on it) no history of skin disease. No other skin cooler changes have occurred.
Hair: No recent hair loss, or change in texture.
Nails: No change in shape, color or brittleness.
Head: No recent headaches, injuries, or dizziness, syncope or vertigo.
Eyes: No difficulty with