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Health History Form

Two to three a week per patient. Patient also has complaints of nausea, vomiting, neck tension, and photosensitive. Past Medical History: Patient has a medical history of hypertension diagnosed in 2010. For which she takes an ACE Inhibitor for. Patient has also had a history of one vaginal birth with no complications. Childhood Illness: Patient denies any illnesses or diagnoses prior to 2010. Immunization: Patient states her immunization are required to be up to date by her employer.

Allergies (past and present) None applicable Medications: _ None applicable Environmental: _ None applicable Current Medications including ETC: Illusionist MGM, Marina Hospitalizing/Serious Illness/Surgery, include year: Vaginal non complicated livery 2009 Accidents/Falls: Patient states she has not had any accidents or falls. Obstetrical History (If applicable): Patient had non complicated vaginal delivery. Sexual History: Patient is actively participating in sexual activity with her husband. Patient states she has only had three male partners in her lifetime.

Emotional Status (past and present): Patient states she has been experiencing some additional stress from work. Otherwise no complaints or history of complaints at this time. Mental Health Status (past and present): Patient states she does not have any history f mental health problems. Alterations in cognitive abilities (if noted perform mini mental): Patient currently able to perform all task normally per pat. Sleep History: Patient reports having a “normal” sleep cycle until recently with the added stress from work. Lately she cannot sleep 7-8 hours throughout the night, she “tosses and turns” per pat.

This has been occurring for about a month. Family History: Patients family history includes Hypertension, type 2 diabetes, high cholesterol, depression, OTOH abuse, bipolar disorder, AM’, C.V., hypothyroidism, and vitamin D deficiency. Patient states she is unsure of all the medical history but this is what she is aware of. SONOGRAM (Diagram family sonogram: three generations including client): Note: May use Powering or computer drawing tools. Available tool for the sonogram: http://www. Prognosticates. Com/online-pedigree/ Please see attached sheet.

Social History: Patient has been married for six years. Husband is employed full time. Patient is a mother to a four year old son. Patient states “l have a great relationship with both my parent’s and my husband parent’s. ” Patient states she does not speak to her sister and hasn’t for twelve years. When asked why she didn’t communicate to her sister patient stated “she is not in the state and nothing but a mess, my family has disowned her from her being a druggie. ” Risk behaviors: a) Tobacco: Patient was a one pack a day smoker for nine years. ) Alcohol: Patient was a social drinker from the ages of 18-22 but will only have a drink for a “wedding” since the age of 22. C) Drugs: Patient states she does not use any drugs. D) Other including lack of exercise: Patient states “l have a very physical Job that requires me to stand and walk a lot. I probably could use to get to the gym Hough. ” Occupational History: Patient currently works as a Pharmacy Technician and has done the same type of work for fifteen years. Prior to working in a pharmacy setting patient was a student and did not work.

Patient has no history of affiliation with any military. Although “working every other Sunday marks it hard to attend. ” Per patient. Living Arrangements: Patient and her husband own a private two story residence. In which they reside with their son. Pets: Patient states she does not have any pets. Heat system/Air conditioning: Patient states the house was built five years ago and ad a brand new central heat and air unit installed prior to them moving in. Indoor Plumbing: Patient states she does have working indoor plumbing.

Kitchen facilities: Patient has all necessary kitchen appliances for cooking and maintain house. Steps or other potential barriers to mobility: Patient states she does have a second floor which takes about fourteen steps to get to; however they have side rails on both sides and maintain a child safety gate at the top and bottom of the stairs due to their son. Educational History: Patient has attended an eight month course to obtain her Certified Pharmacy Technician license. Economic Status: Patient states he family is considered to be middle class by the “government’s standards. Per patient. Pattern of Health Care: Insurance: Patient states she has Blusterous and Blushed though her husband’s employer. Annual preventive and primary exams: Patient states she is bad about attending yearly checkups, however does have an annual pap smear performed. Dental Exams: Patient states she should see the dentist, “it’s been about 4 years, since I have been. ” Self-care habits I. E. Stress reduction walking, exercise, prayer, monthly SUB, SET, seat belt use: Patient reports attending her church services at least twice monthly and wearing her settable regularly.

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