Youngstown State University

Department of Nursing

NURSG 2643

HEALTH HISTORY DOCUMENTATION FORM

Date of Interview: 11-1-15 Interviewer: Michael Turnbull

I. Biographical Data:

Age: 17 Birth Date: 10/28/98

Birthplace:Youngstown, Ohio

Sex: Male Marital Status: Single Race: Caucasian/White

Ethnic Origin: German

Usual Occupation: N/A

Present Occupation: Handel’s Ice Cream Scooper

II. Source of Data: Patient-Subjective

III. Reason for Seeking Care (Chief Complaint):

Head to Toe Physical

IV. Present Health (History of Present Illness):

No present Illness.

V. Past Health (Past History):

A. Childhood Illness/Immunizations

i. Patient confirms having strept throat in the past. No other past history of

measles, mumps, rubella, pertussis, pneumonia, chicken pox, rheumatic

fever, scarlet fever, or poliomyelitis. Patient also confirms having all of

 the required immunizations as a child, which includes:

measles/mumps/rubella, poliomyelitis, diphtheria/pertussis/tetanus,

hepatitis B & hepatitis A (in selected areas), and pneumococcal vaccine.

Patient states having last tetanus immunization in the sixth grade, and

last flu shot August 15th, 2015. The patient does not recall having a

tuberculosis skin test.

B. Accidents or Injuries:

i. Patient reports having an scar on inner right leg from a dirt bike engine.

No reports of auto accidents, head injuries, or fractures.

C. Serious or Chronic Illnesses:

i. Patient denies having hypertension, heart disease, HIV infection,

hepatitis, asthma, diabetes, sickle-cell anemia, cancer, or any seizure

disorders.

D. Hospitalization and Operations:

i. Patient has had a tonsillectomy by Dr. Babyak at Southwoods Surgical

Center.

E. Obstetric History:

i. Patient does not report any obstetric history due to his gender.

F. Adult Immunizations:

i. Patient is under 18 so it is not applicable.

 G. Last Examination Date:

Patient has had a physical in Aug. 2015, a dental in July 2015, and has had a

vision and hearing test around a year ago from his high school. Patient hasn’t had

an ECG, or a chest x-ray examinations.

H. Allergies/Reactions:

i. Patient confirms having seasonal allergies. Patient also confirms rash,

hives, itching, runny nose, and watery eyes during an allergic reaction.

How would you describe your health?

Patient states, “I am feeling like an alpha male, ‘A1’!”

VI. Medications:

A. Patient confirms taking over-the-counter Ibuprofen (400mg) and Zyrtec (10mg)

as needed.

VII. Family History (include family tree): Patient states his parents are moderate drinkers

and do not consume any tobacco, they’re certain cancers that run in his family along

with hypertension, diabetes mellitus, arthritis, and lactose intolerances.

VIII. Social History, Culture, Religion, Education:

 A. Patient is in the 11th grade at Poland Seminary High School. Patients also states

he attends church a few Sundays a month. He belongs to Poland United

Methodist Church.

IX. Review of Systems:

A. General Overall Health State:

i. Patient confirms weight of 157lbs with a height of 5’11” and denies

fatigue, weakness/malaise, fever, chills, sweats and/or night sweats.

B. Skin:

i. Patient confirms experiencing hives and rash from the allergic reactions..

Patient denies and history of skin disease such as eczema, psoriasis, or

excessive moisture, dryness, pruritus, and/or any pigment/color changes

in moles. Patient denies getting bruised easily.

C. Hair:

i. Patient denies any recent hair loss, change in texture, and change in

color.

D. Nails:

i. Patient stated, “My nails are very well kept, clean, and thin.”

E. Head:

i. Patient denies having any head injuries such as frequent or severe

headache, any head injury, dizziness(syncope), or vertigo.

F. Eyes:

i. Patient has 20/20 vision but confirms having itching and redness at times

because of seasonal allergies and denies having difficulty with vision

(decreased acuity, blurring, blind spots,) eye pain,diplopia (double vision),

redness or swelling, watering or discharge and glaucoma or cataracts.

G. Ears:

i. Patient denies having any hearing loss, infections, earaches, discharge,

tinnitus, and vertigo.

H. Nose and Sinuses:

i. Patient denies any frequent colds, sinus pain, nosebleeds, or hay fever,

discharge, or changes in smell. Patient confirms having a deviated septum

where his airway isn’t as efficient in his left nare and a runny nose during

allergic reactions.

I. Mouth and Throat:

i. Patient denies mouth pain, frequent sore throats, voice changes,

toothaches, lesions in mouth or on tongue, dysphagia, altered taste,

hoarseness, or tonsillectomy.

J. Neck:

i. Patient denies pain, enlarged or tender nodes, swelling, goiters, or

limitations of movement.
K. Breast:

i. Patient denies pain, unusual lumps and swelling, nipple discharge, breast

disease and rashes. Patient also denies any breast operations.

L. Axilla:

i. Patient denies any tenderness, unusual lumps, rashes, and swelling.

M. Respiratory System:

i. Patient denies having asthma, emphysema, and tuberculosis. Patient also

denies chest pain with breathing, bronchitis, pneumococcal pneumonia,

wheezing, hemoptysis, toxin/pollution exposure, and excessive coughing

and sputum with strenuous activities.

N. Cardiovascular System:

i. Patient denies precordial and retrosternal pain, palpitation, cyanosis,

dyspnea during inhalation and exertion, orthopnea, paroxysmal nocturnal

dyspnea, nocturia, edema, and history of heart murmurs, hypertension,

coronary artery disease, or anemia.

O. Peripheral Vascular System:

i. Patient denies coldness, tingling, cyanosis of hands, numbness in hands

and feet, swelling of the legs, varicose veins, intermittent veins,

intermittent claudication, thrombophlebitis, and ulcers.

P. Gastrointestinal System:

i. Patient denies changes in appetite, food tolerance, dysphagia,

indigestion, abdominal pain, pyrosis, pain associated with eating, nausea,

 vomiting, history of ulcers, liver/gallbladder disease, jaundice,

appendicitis, and colitis, flatulence, constipation, rectal bleeding,

diarrhea, changes in stool characteristics, rectal bleeding, hemorrhoids,

fistulas, black stool, and changes in bowel movements.

Q. Urinary System:

i. Patient denies polyuria, dysuria, oliguria, incontinence, history of kidney

disease/kidney stones, pain in groin, flank, suprapubic region and/or

lower back, changes in urine color, and straining and narrowing of urine.

R. Male/Female Genital System:

i. Patient confirms that he does not have any penis or testicular pain, sores

or lesions, penile discharge, lumps or hernia.

S. Sexual Health:

i. Patient states, “I am sexually active and satisfied by my partner.” Patient

confirms using condoms and denies having any sexually transmitted

diseases.

T. Musculoskeletal System:

i. Patient states he does not have any history of arthritis or gout. In the

joints, the patient has no pain, stiffness, swelling, deformity, limitation of

motion, noise with joint motion. In the muscles, the patient denies any

pain, weakness, gait problem, or problem with coordinated activities.

Also in the back, the patient denies pain, stiffness, limitation of motion,

disk disease or history of back pain.

 U. Neurologic System:

i. Patient denies any history of seizure, stroke, fainting, or blackouts.

Patient also states he does not have motor, sensory, cognitive, or mental

status problems.

V. Hematologic System:

i. Patient denies any bleeding tendency of skin or mucous membranes,

excessive bruising, lymph node swelling, exposure to radiation,

chemical/toxic agents or blood transfusion and reaction.

W. Endocrine System:

i. Patient states he has no 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, and need for hormone therapy.

X. Functional Assessment:

A. Self-Esteem/Self-Concept:

i. Patient believes he has a good out-look on life with strong relationships

with his family and friends. Patient states that he has a job and it provides

him with spending money so “It gets the job done.” Patient also states

that a strength of his is his communication skills.

B. Activity/Exercise:

i. Patient confirms playing soccer and lacross, work, “his partner”, he also

spends a lot of time with his family and friends.

C. Sleep/Rest:

i. Patient states that he “strives for 8 hours a night”.

D. Nutrition/Elimination:

i. Patient recalls his diet in the past 24 hours as follows:

1. For breakfast, the patient ate a bowl of lucky charms

2. For lunch, the patient consumed two PB&J sandwiches, a bag of

Doritos, apple sauce, and a Debbie Cake.

3. For dinner, he got “Chipotle with his companions.”

ii. Patient states that the finances are adequate for food and his mother is

usually the one that purchases and prepares the meals in the house.

iii. Patient also does not recall any problems in bowel or urinal elimination.

E. Interpersonal Relationships/Resources:

i. Patient states that he is the example child and he gets along with everyone.

He copes by having “me time” and he feels comfortable talking to his

manger and sister.

F. Coping and Stress Management:

i. The patient says, “When I have a problem, I like to talk it out with either

my manager or sister for advice.” The patient says that his way of coping

with stress is to have “me time”, this isolation lets him relax.

G. Personal Habits:

i. The person states he consumes adult beverages moderately. He states it in

a laughing matter and says that “It is accepted by his parents to drink at

dinner with them.”

H. Environment/Hazards:

i. The patient states that he does not have any environmental hazards, feels

safe at home and is provided with all the necessities to live a healthy life.

I. Occupational Health:

i. The person says that he does not have any occupational hazards and if

there is a situation he uses gloves. There may be a concern with repetitive

motion within his arm. He is an ice cream scooper at Handel’s. He loves

the job because it is relaxing and has a high moral.

J. Perception of Health

i. Patient states, “Health to me is being healthy, I have no clue dude.”