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Youngstown State University

Department of Nursing

NURSG 2643

HEALTH HISTORY DOCUMENTATION FORM

Date of Interview: 10/29/16 Interviewer: Danielle Pelini

I. Biographical Data:

Client's Initials: ZKJ

Age: 22 Birth date: 09/30/1994 Birthplace: Lincoln, NE

Sex: Male Marital Status: Single Race: Caucasian Ethnic Origin: Danish,
Native American

Usual Occupation: Retail

Present Occupation: Retail

II. Source of Data: The patient himself, who seems reliable.

III. Reason for Seeking Care (Chief Complaint):

Patient seeks routine health exam.

IV. Present Health (History of Present Illness):

“I am healthy and I try to stay active.”

V. Past Health (Past History):

A. Childhood Illness / Immunizations: Patient confirms having chickenpox.
Patient denies having measles, mumps, or rubella as a child. Patient also denies
history of rubella, rheumatic fever, scarlet fever, or poliomyelitis. Patient received
vaccinations for all of the stated illnesses between ages 3-5 years old.

B. Accidents or Injuries: Patient reports broken fingers (age 13) requiring

splints, torn left labrum (age 17), two concussions (age 14 and 16) requiring
hospitalization. Patient denies any auto-accidents or burns.

C. Serious of Chronic Illnesses: Patient confirms being diagnosed with manic

depression and anxiety (at age 14). Patient denies having asthma, diabetes,
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hypertension, heart disease, HIV infection, hepatitis, sickle-cell anemia, cancer, or

any seizure disorder.

D. Hospitalizations and Operations: Patient confirms being hospitalized for

concussions but has not required any operations.

E. Obstetric History: N/A

F. Adult Immunizations: Patient denies having MMR, polio, diphtheria-

pertussis-tetanus, varicella, hepatitis A and B, meningococcal, HPV, haemphilus
influenza type b, pneumococcal, and influenza vaccines. Patient cannot recall last
Tetanus shot and denies ever having a tuberculosis skin test.

G. Last Examinations Date: Patient confirms last physical was three years ago
(2013), last dental was in November of 2015, last ECG and chest x-ray was five
years ago (2011). Patient cannot recall last hearing or vision test. Patient denies
having stool or serum cholesterol count.

H. Allergies/Reactions: Patient confirms having allergies to penicillin, pollen,

bees, and cats. Patient confirms itching, runny nose, water eyes, and difficulty
breathing associated with allergic reactions. Patient denies having allergies to
food.

How would you describe your health?

“I feel healthy. I try to eat well and stay active. This way I don’t experience any
preventable limitations in my health.”

VI. Medications:

Patient denies taking any medications.

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VII. Family History (include family tree):

Patients grandfather (mother’s side) had multiple strokes and passed away from heart
problems. Patient’s grandmother (mother’s side) has high blood pressure. Patients
grandfather and grandmother (father’s side) died young in a car accident and experienced
no serious health issues before then. Patients mother diagnosed with melanoma, high
blood pressure and arthritis. Patients father has no known health issues at this time.
(Family tree attached)

VIII. Social History, Culture, Religion, Education:

Patient doesn’t smoke or do drugs but drinks occasionally (0-2 drinks a week). No
religious background. Patient confirms spending time with close friends or family at least
once a week. Patient received high school diploma (2013) and is a current online student
at Western Oklahoma State.

IX. Review of Systems:

A. General Overall Health State: Currently 195 pounds, slight increase (over the past
year) due to a decline in physical activity. Patient denies fatigue,
weakness/malaise, fever, chills or night sweats.

B. Skin: Patient denies any history of skin disease such as eczema, psoriasis, and
hives, excessive moisture, dryness, pruritus, rashes, bruising, lesions, and any
pigment/color changes in moles,

C. Hair: Patient denies recent hair loss, change in texture or change in color.

D. Nails: Patient denies change in shape, color, or brittleness of nails.

E. Head: Patient denies frequent headaches or migraines. Patient denies head

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injuries, syncope, or vertigo.

F. Eyes: Patient denies wearing glasses or contacts. Patient denies eye pain, diplopia,
redness/swelling, watering, cataracts or glaucoma.

G. Ears: Patient denies earaches, infections, discharge, tinnitus, or vertigo. Patient

cleans ears with tip of washcloth.

H. Nose and Sinuses: Patient denies discharge or severe/frequent cold, sinus pain,
nasal obstructions, nosebleeds, allergies, hay fever, or change in sense of smell.

I. Mouth and Throat. Patient denies mouth pain, frequent sore throats, bleeding
gums, toothaches, lesions in mouth or tongue, dysphasia, hoarseness, altered taste,
tonsillectomy or voice change.

J. Neck: Patient denies pain, lumps, swelling, goiters, enlarged/tender nodes, and
any limitation of movement.

K. Breast: Patient denies pain, unusual lumps and swelling, nipple discharge, and
rashes. No gynecomastia.

L. Axilla: Patient denies unusual lumps, tenderness, swelling or rashes.

M. Respiratory System: Patient denies history of lung disease. Patient denies chest
pain with breathing, wheezing, or loud breathing, SOB, cough, sputum production
or exposure to pollution.

N. Cardiovascular System: Patient denies precordial or retrosternal pain. Patient

denies palpitations, cyanosis, dyspnea (on inhalation or exertion), orthopnea,
paroxysmal nocturnal dyspnea, nocturia, edema, and history of heart murmurs,
hypertension, CAD, or anemia.
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O. Peripheral Vascular System: Patient denies coldness, numbness/tingling, or

swelling in extremities. Patient confirms no 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/during eating, nausea or vomiting, history of
abdominal diseases, or abnormal flatulence. Patient confirms about one bowel
movement per day with no recent abnormalities or changes in stool (rectal
bleeding, diarrhea, constipation, fistulas, black stools, or hemorrhoids).

Q. Urinary System: Patient denies dysuria, polyuria, oliguria, incontinence, hesitancy

or straining, narrowing of stream, or cloudy urine. Patient denies history of
urinary disease, or pain in flank/groin/suprapubic/low back regions.

R. Male Genital System: Patient denies penis or testicular pain, sores or lesions.
Patient denies penile discharge, lumps or hernia. Patient performs testicular self-
examination 1-2 times a month.

S. Sexual Health: Patient is in sexual relationship. Patient uses condoms and partner
uses oral contraceptive. No change in erection or ejaculation.

T. Musculoskeletal System: Patient denies history of gout or arthritis. Patient denies

joint pain, muscle pain, stiffness, swelling, deformity, limited ROM, or noise
associated with joint movement. Patient denies cramps, weakness, gait problems,
or trouble with coordinated activities. Patient denies stiffness in the back, limited
ROM, or history of back pain.

U. Neurologic System: Patient confirms diagnosis of anxiety and manic depression at

age 14, bur no other history of mental health dysfunction or hallucinations. Patient
is oriented. Patient denies history of seuizures, stroke, fainting, or blackouts.
Patient denies weakness in motor function, coordination problems, tremors,
paralysis, numbness or tingling. Patient denies history of memory disorders.

V. Hematologic System: Patient denies excessive bruising, history of blood

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transfusions or reactions, or exposure to toxic agents or radiation. Patient

confirms lymph nodes swell excessively when ill.

W. Endocrine System: Patient denies history of diabetes or diabetic symptoms,

thyroid disease, intolerance to heat or cold, changes in skin pigmentations and
texture, excessive sweating, abnormal hair distribution, nervousness, tremors, or
need for hormone therapy.

X. Functional Assessment:

A. Self-Esteem/Self-Concept: Patient confirms receiving good grades as an online

student at Western Oklahoma State University. Financial status is adequate for
lifestyle. No religious practice. Describes personal strength as “hardworking.”
Patient claims to be content with where he is in his life.

B. Activity/Exercise: Patient confirms working in retail, and claims to walk around

all shift. Patient confirms working out at least twice a week by running for cardio
followed by lifting weights. Patient does not need assistance with activities of
daily living.

C. Sleep/Rest: Patient confirms 5-8 hours of sleep each night. Patient denies naps
during day or use of sleep aids.

D. Nutrition/Elimination: Last 24 hours: Patient reports eating a bagel with cream

cheese and drinking a glass of orange juice for breakfast, a sandwich and some
chips with a glass of chocolate milk for lunch, and grilled chicken with sides of
mashed potatoes and corn with water to drink for dinner. Patient confirms this is a
normal daily consumption with modifications from day to day. Patient denies any
sort of food allergies, intolerance, unusual bowel elimination and urinating
problems with mobility or transfer in toileting, continence, and use of laxatives.

E. Interpersonal Relationships/Resources: Patient confirms he gets along with

family, friends, and co-workers. Patients support system consists of family (mom,
dad, big sister, big brother) girlfriend, and friends. He plays an active role in the
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family and is there for all of those people if they need help and he seeks help from
them when needed. Does not mind some time alone. “I don’t mind being my own
good company sometimes.”

F. Coping and Stress Management: Patient confirms experiencing stress due to

schoolwork as well as family issues. Patient confirms stress is higher in the past
year due to moving to Ohio, away from his family, after living in Nebraska for the
past 21 years. Patient confirms playing video games or hanging out with girlfriend
while feeling stress as a form of stress relief (effective for patient). Patient denies
any new lifestyle changes, but has confirmed a new additional stress. Patients
mother was diagnosed with melanoma one week ago.

G. Personal Habits: Patient confirms he used to smoke Cigarettes but quit two over
years ago. Patient confirms that he has smoked a few cigarettes since he quit, but
mostly uses an electronic cigarette now. Patient denies using chewing tobacco or
street drugs. Patient is 22 years old and said he’s had 5-6 drinks in the last 30
days.

H. Environmental/Hazards: Patient confirms no hazards reported in work place or

home. Lives with family in a house with adequate heat and utilities. Wears
seatbelt and denies traveling out of the country or geographical exposures.

I. Occupational Health: Patient confirms currently working in retail. Patient denies

health hazards such as asbestos, inhalants, chemicals, health problems related to
work exposure, and repetitive motions. Patient denies need to wear any protective
equipment or need for work programs. Patient is currently satisfied with his job.