Youngstown State University

Department of Nursing

NURS 2643
HEALTH HISTORY DOCUMENTATION FORM

Date of Interview: 10/18/15 Interviewer: Rebecca Platt

I. Biographical Data:

Client's Initials: D.L.P

Age: 52 Birth date: 06/20/1963 Birthplace: Beaver Falls, PA

Sex: F Marital Status: Married Race: Caucasian Ethnic Origin: Caucasian

Usual Occupation: Vision Center Manager

Present Occupation: Vision Center Manager

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

III. Reason for Seeking Care (Chief Complaint):

Physical Assessment

IV. Present Health (History of Present Illness):

“I am in good health right now”

V. Past Health (Past History):

A. Childhood Illness / Immunizations:

Chickenpox at age 3, strep throat at about age 23; denies measles, mumps, rubella,
pertussis, rheumatic fever, scarlet fever, poliomyelitis.
 B. Accidents or Injuries:

Denies any auto accidents, fractures, penetrating wounds, head injuries, or burns

C. Serious of Chronic Illnesses:

Hypertension; denies asthma, depression, diabetes, heart disease, HIV infection,

hepatitis, sickle-cell anemia, cancer, or seizure disorder

D. Hospitalizations and Operations:

Tubal ligation at Northside Medical Center, Dr. Kramer, recovered well

E. Obstetric History:

Grav 3, Term 3, Preterm 0, Ab 0, Living 3; sex=F, 7 lbs 2 oz.; sex=F, 6 lbs 13 oz.;
sex=F, 7 lbs 7 oz.

F. Adult Immunizations:

Reports all immunizations are met; Last tetanus shot 7 years ago, Tb 5 years ago, flu shot
done this year.

G. Last Examination Date:

Physical: this year, dental: this year, vision: this year, chest x-ray: last year; denies having
hearing, and EKG.
 H. Allergies / Reactions:

Allergic to Sulfa-rash; denies food allergies.

How would you describe your health?

“My health is good.”

VI. Medications Dose Dosage Times

1. Benicar 20 mg Once daily
2. Fluoxetine 20 mg Once daily
3.
4.
5.
6.
7.
8.
9.
10.
VII. Family history:
Grandfather died black lung, Grandmother died from cancer in the uterus, Mother died of
emphysema, Uncle died from cancer, Father died from unknown causes; client does not know her
Father.

VIII. Social History, Culture, Religion, Education:

Client is married, has 3 daughters and works full time. She smokes ½ PPD x 30. She does
not drink alcohol or do illicit or street drugs. She enjoys spending time with family. She is
Baptist and attends church during holidays. She has her high school diploma.

IX. Review of Systems:

A. General Overall Health State:
Denies weight gain or loss, fatigues, malaise, fever, chills, sweats or night sweats

B. Skin:

Denies eczema, psoriasis, hives, pigment or color change, change in mole, excessive
dryness or moisture, pruritis, excessive bruising, rash or lesions.
C. Hair:

Denies recent loss, change in texture; Amount of sun exposure is minimal. Uses skin
lotion and washes hair daily.

D. Nails:

Denies change in shape, color, or brittleness

E. Head:

Denies any unusually frequent or severe headache, head injury, dizziness, or vertigo.

F. Eyes:

Wears glasses and contacts, last vision check this year; denies difficulty with vision, eye
pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts.
G. Ears:
Earaches and infections with colds; denies discharge, tinnitus, or vertigo.

H. Nose and Sinuses:

Sinus pain seasonally; denies any unusually frequent or severe colds, nasal obstruction,
epistaxis, allergies, or change in sense of smell

I. Mouth and Throat:

Denies mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue,
dysphagia, hoarseness or voice change, tonsillectomy, altered taste; brushes teeth twice daily,
last dental check up this year.

J. Neck:

Denies neck pain, limitation of motion, lumps, swelling, enlarged or tender nodes, goiter.

K. Breast:

Denies pain, lump, nipple discharge, rash, history of breast disease, surgery on breasts;
performs BSE monthly, last mammogram done this year.

L. Axilla:

Denies tenderness, lump, swelling, or rash.

M. Respiratory System:

Denies history of lung diseases, chest pain, wheezing, SOB, hemoptysis, toxin exposure;
last chest x-ray done last year.
N. Cardiovascular System:

Hypertension; denies chest pain, pressure, tightness or fullness, cyanosis, dyspnea on exertion,
orthopnea, nocturia, edema, history of heart murmur, coronary heart disease, or anemia; denies
having ECG or other heart tests.

O. Peripheral Vascular System:

Denies coldness, numbness and tingling, swelling of legs, discoloration in hands or feet, varicose
veins, intermittent claudication, thrombophlebitis, ulcers; reports both sitting and standing at job.

P. Gastrointestinal System:

Denies changes in appetite, food intolerance, dysphagia, heartburn, indigestion, pain

with eating, abdominal pain, pyrosis, N/V, hemoptysis, history of abdominal disease,
flatulence, changes in bowel movements, constipation or diarrhea, rectal bleeding.

Q. Urinary System:

Denies urgency, nocturia, dysuria, polyuria or oliguria, hesitancy or straining, change in

urine color, incontinence, history of urinary disease, pain in flank or groin.

R. Male/Female Genital System:

Menopause at age 45; denies vaginal itching, discharge, postmenopausal bleeding.

S. Sexual Health:

Sex satisfactory to client and partner; denies dyspareunia, contraceptive use. Partner with no
sexually transmitted infections.

T. Musculoskeletal System:

Denies history of arthritis or gout; denies joint pain stiffness, swelling, deformity, limitation
of motion, crepitation; denies muscle pain, cramps, weakness, gait problems; denies back
pain, stiffness, limitation of movement, or history of back pain or disk disease.

U. Neurologic System:

Denies history of seizure disorder, stroke, fainting, blackouts; denies motor function
weakness, tic or tremor, paralysis, or coordination problems; denies memory disorder,
nervousness, mood change, depression, or history of mental health dysfunction,
hallucinations.
 V. Hematologic System:

Denies bleeding tendency skin or mucous membranes, excessive bruising, lymph

node swelling, exposure to toxic agents, blood transfusion.

W. Endocrine System:

Denies history of diabetes or diabetic symptoms, history of thyroid disease, intolerance to

heat and cold, change in skin pigmentation or texture, excessive sweating, abnormal hair
distribution, nervousness, tremors, or need for hormone therapy.

X. Functional Assessment:
A. Self-Esteem/Self-Concept:
Educational level is high school diploma, income adequate for lifestyle.

B. Activity/Exercise:

Independent; enjoys spending time with family and walking; Walks about 30
minutes 1-2 times per week.

C. Sleep/Rest:

Sleeps about 5-6 hours a night, no daytime naps.

D. Nutrition/Elimination:

Client had egg and cheese sandwich for breakfast, tuna salad sandwich for lunch, and pizza
for dinner, with 1 bottle of water and 2 cups of Diet Pepsi. Diet changes daily. Buys own
food and prepares dinners occasionally for family. Finances are adequate for food. Drinks
approximately 5 cups of caffeine daily. Denies abnormal bowel movements and any
abnormal urination.

E. Interpersonal Relationships/Resources:

Describes a dominant role in family; gets along good with family, friends and co-workers;
would report to husband for support; time spent alone is pleasurable.

F. Coping and Stress Management:

Work stressful in the past year; denies any change in lifestyle or current stress; deep breathing
techniques are used to help relieve stress and reports that they are helpful.

G. Personal Habits:
Smokes cigarettes, ½ PPD x 30; client has quit occasionally for a couple of years; client
felt better after quitting; does not drink alcohol or do illicit drugs.
H. Environment/Hazards:

Lives with family in a safe neighborhood; has heat and utilities, a car; denies of any
environmental hazards at home or job; uses seatbelt any time in the car.

I. Occupational Health:

Denies working with any health hazards such as asbestos, inhalants, or chemicals.