Youngstown

State University
Department of Nursing

NURSG 2643
HEALTH HISTORY DOCUMENTATION FORM

Date of Interview: 11/2/16 Interviewer: Natalie Laurence

I. Biographical Data:
a. Client’s Initials: M.W.
b. Age: 19
c. Birth Date: 12/09/1996
d. Birthplace: Buffalo, New York
e. Sex: Female
f. Marital Status: Single
g. Race: Caucasian
h. Ethnic Origin: Irish
i. Usual Occupation: Student at Youngstown State University
j. Present Occupation: Student at Youngstown State University

II. Source of Data: Patient

III. Reason for Seeking Care (Chief Complaint): “I am here for my physical.”

IV. Present Health (History of Present Illness): “I am healthy and relatively active.”

V. Past Health (Past History):
a. Childhood Illness/Immunizations: Patient did not have chicken pox, measles,
mumps, pertussis, rheumatic fever, scarlet fever, strep throat, or rubella as a
child. Patient claims to have received vaccines for these illnesses when they
 were supposed to. Patient says parents always kept on top of the vaccines
needed.
b. Accidents or Injuries: Patient never has broken or fractured a bone, has had a
head injury, or burn. Patient denies being in a serious auto accident.
c. Serious Chronic Illnesses: Patient denies having diabetes, heart disease, cancer,
depression, hypertension, anemia, hepatitis, HIV, or any seizure disorder. Patient
has seasonal, cat, and dust allergies.
d. Hospitalizations and Operations: Patient denies being hospitalized or being
required to have operations done.
e. Obstetric History: N/A
f. Adult Immunizations: Patient does not receive a flu shot every year. Last flu shot
was received 5 years ago (2011). Last TB test was this past summer (June 2016).
Patient claims to be up to date on all the following immunizations: MMR, DTP,
varicella, and Hep. B. Patient does not recall when she received her last tetanus
shot.
g. Last Examination Date: Last physical was two years ago (2014). Last dental
appointment was this past summer (2016). Last vision exam was a year ago
(2015). Patient denies having a hearing test, electrocardiogram, or chest ray
examinations done.
h. Allergies/Reactions: Patient has seasonal allergies, dust allergies, and cat
allergies. Seasonal allergy reactions are a runny nose, dry eyes, wheezing, and
coughing. Patient claims that dust and cat allergy reactions are the same as her
seasonal allergy reactions.

VI. How would you describe your health? “I feel healthy. I work out about 3 times a week. I
try to eat a well-balanced diet. I have never had limitations to my health (unless you
include asthma).


VII. Medications: Dose Dosage Times
Flonase- 2 sprays each nostril twice a day- taken when seasonal and dust allergies
appear
Budesonide- take one inhale every day- taken every day to prevent allergies and help
with asthma
One a Day Women’s Vitamins- 1 capsule- 1 per day (taken in the morning with
breakfast)

VIII. Family History (include family tree): look at attached family tree for information

IX. Social History, Culture, Religion, and Education: Patient denies engaging in smoking,
doing drugs, or drinking alcohol. Patient is catholic and attends mass every Sunday
morning. Patient is a second year nutrition student at Youngstown State University.


X. Review of Symptoms:
a. General Overall Health State: Patient is currently 130 pounds and 5 feet 5 inches
in height. Patient denies recent weight gain/loss, fatigue, weakness/malaise,
fever, chills, or night sweats.
b. Skin: Patient denies having any eczema, psoriasis, hives, pigment change,
pruritus, bruising, rash, or lesions. Patient has multiple freckles on arms, chest,
and face.
c. Hair: Patient denies recent hair loss or change in texture.
d. Nails: Patient denies change in shape, color, or brittleness.
e. Head: Patient denies frequent headaches or migraines. Patient denies any head
injuries, vertigo, or syncope.
f. Eyes: Patient wears contacts and glasses because she is nearsighted. Patient
denies eye pain, diplopia, redness/swelling, watering of the eyes, cataracts, or
glaucoma.
g. Ears: Patient cleans ears every day with a Q tip. Patient denies earaches,
infections, discharge, tinnitus, or vertigo.
h. Nose and sinuses: Patient denies discharge or severe colds, sinus pain, nasal
obstruction, or change in sense of smell. Patient claims to have dust, seasonal,
and cat allergies.
i. Mouth and Throat: Patient denies mouth pain, frequent sore throats, bleeding
gums, toothaches, lesions in mouth or tongue, dysphasia, hoarseness, altered
taste, or voice change. Patient denies having a tonsillectomy.
j. Neck: Patient denies pain, limited ROM, lumps, enlarged/tender lymph nodes, or
goiter.
k. Breast: Patient denies gynecomastia.
l. Axilla: Patient denies swelling, lumps, tenderness, or rash.
m. Respiratory system: Patient denies history of lung disease, chest pain with
breathing, SOB, and sputum production. Patient has mild chest pain with
wheezing or loud breathing while exposed to pollen, dust, and cats.
n. Cardiovascular system: Patient denies precordial or retrosternal pain. Patient
denies palpitations, cyanosis, dyspnea on exertion, orthopnea, paroxysmal
nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension,
CAD and anemia.
o. Peripheral Vascular system: Patient denies coldness, numbness, tingling, and
swelling in extremities. Patient denies discoloration in hands or feet, varicose
veins, intermittent claudication, thrombophlebitis, or ulcers.
p. Gastrointestinal system: Patient denies food intolerances, problems with
appetite, pyrosis, indigestion, pain after or during eating, nausea or vomiting,
history of abdominal diseases, or abnormal flatulence. Patient denies taking
antacids. Patient claims to have regular bowel movements without any
abnormalities (rectal bleeding, diarrhea, constipation, black stools, or
hemorrhoids.
q. Urinary system: Patient denies dysuria, polyuria, oliguria, hesitancy or straining,
narrowing of stream, or cloudy urine. Patient has no history of urinary disease or
pain in flank/groin/suprapubic/lower back regions.
r. Female Genital system: Patient claims menarche began at age 12. Her last
menstrual period was last week (week of October 31, 2016). Her cycle is normal
and lasts around one week. Patient denies premenstrual pain, spotting, vaginal
itching, discharge, menopausal signs and symptoms.
s. Sexual health: Patient denies ever engaging in a sexual relationship or ever
engaging in sexual activity.
t. Musculoskeletal system: Patient denies history of arthritis or gout, joint pain,
swelling, stiffness, deformity, limited ROM, or noise associated with joint
movement. Patient denies any muscle pain, cramps, weakness, gait problems, or
trouble with coordinated activity. Patient denies stiffness in lower extremities,
limited ROM, or history of lower back pain or disk disease.
u. Neurologic system: Patient denies history of seizures, stroke, fainting, and
blackouts. Patient denies weakness in motor function, tremors, and paralysis.
Patient denies tingling and numbness. Patient denies history of memory
disorders, nervousness, mood changes, and depression. Patient denies history of
mental health dysfunctions and hallucinations.
v. Hematologic system: Patient denies excessive bruising, lymph node swelling,
history of blood transfusions/reactions, and exposure to toxic agents/radiations.
Patient denies bleeding of the skin or mucous membranes.
w. Endocrine system: Patient denies history of diabetes or diabetic symptoms,
thyroid disease, intolerance to heat or cold, change in skin pigmentation,
excessive sweating, abnormal hair distribution, nervousness, tremors, and need
for hormone therapy.



XI. Functional Assessment:
a. Self-esteem/Self-concept: Patient has completed first year of college with a
sophomore status. Patient is currently completing second year on campus.
Financial status is adequate for lifestyle that the patient is currently living.
Patient is a practicing catholic. Patient describes personal strengths as
“organized and self-motivated.”
b. Activity/exercise: Patient does not need extra assistance with daily activities.
Patient works out about 3 times a week by running, completing yoga classes, or
attending a boot camp workout class provided by the campus recreational
center.
c. Sleep/rest: Patient receives about 7 hours of sleep each night. Patient naps
during the day between class times but usually only an hour long nap is needed
per day. Patient denies use of melatonin sleep aids. Patient will take breaks from
exercise if in need of rest.
d. Nutrition/elimination: Patient denies food allergy or intolerance. Patient
consumes about 2 cups of coffee each day but does not drink any other
caffeinated beverages. Finances are adequate for food intake. Meals are usually
consumed at restaurants on campus. The following menu is a typical daily food
intake the patient consumes:
i. Breakfast: 2 cups of coffee, a banana, and a bowl of oatmeal.
ii. Lunch: vegetarian wrap from Chop’d and Wrap’d, a chocolate chip
cookie, bag of chips, and water.
iii. Snack: vanilla protein shake with goldfish.
iv. Dinner: plate of the vegetarian station at Christmans with water or milk.
v. Snack: an apple or grapes.
e. Interpersonal relationships/resources: Patient claims to have good family
relationships and healthy relationships with friends. Patients claims to have an
active role in her family and helps whoever needs some of her assistance.
Patient states her support comes from her family (mom, dad, and younger
 brother) and friends. Patient seeks help when needed and does not mind
spending time alone.
f. Coping and stress management: Patient claims stress comes from school work
and from looking for a job that will cooperate with her already busy schedule.
Patient states she will go on a run or go workout at the gym as a stress relief
technique.
g. Personal habits: Patient denies ever smoking or trying/doing any type of drug.
Patient denies consuming any amount of alcohol in her lifetime so far (only 19).
h. Environment/hazards: Patient claims to wear a seatbelt. Denies wearing a
helmet when going on bike rides. Patient does not report any hazards at her
university or at home. Patient claims to live in a safe area with adequate facilities
to meet her needs. Patient has never traveled out of the country but hopes to
one day.
i. Occupational health: Patient denies ever having a job and currently is
unemployed.