Example Of A Health History Report
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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 vision. No double vision. No inflammation or pain. Looks wore out, may be caused by medication from depression.
Ears: No recent earaches, infections, or discharge. No hearing loss. Patient had no discharge, tinnitus or vertigo.
Nose and Sinuses: No recent colds or sinus pain. No nosebleeds. Hasnt noticed a change in sense of smell.
Mouth and Throat: No mouth pain, not experiencing frequent sore throats. Gums are healthy. No toothaches, sores or lesions in mouth. Brushes teeth twice or more daily and flosses twice a week.
Neck: No neck pain or limitation in motion, no lumps or swelling. No limitation of movement or swollen glands.
Breast: No pain in the chest area, no lumps, no discharge.
Respiratory System: No history of lung disease. No chest pain, breathing is normal. Last chest x-ray was 3 years ago. Patient smokes. Recently has tried quitting. Patient also chews chewing tobacco.
Cardiovascular System: Aware of a Heart Murmur. No chest pain, cyanosis, fatigue or dyspnea.
Peripheral Vascular System: No coldness, numbness or tingling. No pain, swelling in the legs.
Gastrointestinal System: Worried about a stomach ulcer. Does not experience heartburn, patient complains of pain in abdomen, says he is nauseated. Not taking any over the counter medications for his pain.
Urinary System: No problems with urination. No dysuria, frequency, nocturia, hesitancy or straining. Urine color normal no history of kidney disease.
Male Genital System: Normal No pain, no lesions, no discharge.
Female Genital