Health history assignment
Complete Health History Assignment
STUDENT NAME:
Biographical Information
•
•
•
•
•
DOB: 10/06/1987
Gender: female
Race: Caucasian
Ethnicity: French
Additional (Insurance information)
Source and Reliability
•
•
Where does the information come from
What indicators of reliability are there
Reason for Seeking Care
•
CC: headache
History of Present Illness (HPI)
•
Throbbing for the past two hours, can feel pulse in temples, 4 on a scale of 1-10, started while in the student center checking her mailbox; other symptoms: thirsty; has not taken any medications
Past Medical History
•
•
•
•
•
•
•
•
•
General State of Health: good
Past illnesses: none
Chronic Illnesses: minor scoliosis (no pain or limitations)
Injuries and treatments: broken toe in first grade (had crutches); visited a chiropractor
Hospitalizations: none
Surgeries: wisdom teeth removed (Dec. 2002)
Active/Chronic Problems: sports-induced asthma; no limitations; not being treated
Allergies
o Seasonal; no food allergies o Drugs – See medication history below: had a drug reaction to an unknown asthma medicine at age 8
Substance use/abuse o No tobacco use. Drinks wine ~once/month o Recreational drugs: none
1
•
•
•
Exercise: running once every 2 weeks; trying to exercise more regularly; does Yoga once every 2 weeks
Nutrition: “neither overly unhealthy nor healthy”
Sleep Pattern: tries for 8 hours every night; a short nap every couple days
Medication History
•
•
•
•
•
•
•
Current medications: none
Vitamins: no, feels she should
Herbal remedies/health supplements: none
Past medication: Albuterol, d/c’d 2 years ago o Dose: 1 to 2 puffs as needed o Reason for taking: asthma o Reason for d/c: no need for it;
Past medication: Benzaclyn d/c’d six months ago o Dose: topical o Reason for taking: acne o Reason for d/c: trying to find something that would work better
Past medication: another asthma medication
STUDENT NAME:
Biographical Information
•
•
•
•
•
DOB: 10/06/1987
Gender: female
Race: Caucasian
Ethnicity: French
Additional (Insurance information)
Source and Reliability
•
•
Where does the information come from
What indicators of reliability are there
Reason for Seeking Care
•
CC: headache
History of Present Illness (HPI)
•
Throbbing for the past two hours, can feel pulse in temples, 4 on a scale of 1-10, started while in the student center checking her mailbox; other symptoms: thirsty; has not taken any medications
Past Medical History
•
•
•
•
•
•
•
•
•
General State of Health: good
Past illnesses: none
Chronic Illnesses: minor scoliosis (no pain or limitations)
Injuries and treatments: broken toe in first grade (had crutches); visited a chiropractor
Hospitalizations: none
Surgeries: wisdom teeth removed (Dec. 2002)
Active/Chronic Problems: sports-induced asthma; no limitations; not being treated
Allergies
o Seasonal; no food allergies o Drugs – See medication history below: had a drug reaction to an unknown asthma medicine at age 8
Substance use/abuse o No tobacco use. Drinks wine ~once/month o Recreational drugs: none
1
•
•
•
Exercise: running once every 2 weeks; trying to exercise more regularly; does Yoga once every 2 weeks
Nutrition: “neither overly unhealthy nor healthy”
Sleep Pattern: tries for 8 hours every night; a short nap every couple days
Medication History
•
•
•
•
•
•
•
Current medications: none
Vitamins: no, feels she should
Herbal remedies/health supplements: none
Past medication: Albuterol, d/c’d 2 years ago o Dose: 1 to 2 puffs as needed o Reason for taking: asthma o Reason for d/c: no need for it;
Past medication: Benzaclyn d/c’d six months ago o Dose: topical o Reason for taking: acne o Reason for d/c: trying to find something that would work better
Past medication: another asthma medication