Youngstown State University

Department of Nursing

NURS 2643
HEALTH HISTORY DOCUMENTATION FORM
Date of Interview: October 28th, 2015 Interviewer: William Drabenstadt Y00734086
I. Biographical Data:
Client’s Initials: AMC
Age: 20 Birth date: March 30th, 1995 Birthplace: Struthers, Ohio
Sex: Male Marital Status: In a relationship Race: Caucasian
Ethnic Origin: Slovak
Usual Occupation: Lawn Care
Present Occupation: Bowling Alley d/t winter
II. Source of Data: Patient (Reliable)
III. Reason for Seeking Care (Chief Complaint):
Routine Physical Exam
IV. Present Health (History of Present Illness):
“Overwhelming Stress” d/t school, began ~ 2 weeks ago around exam time, first
noticed while studying, 4/10, sleep helps, not subsiding or worsening
V. Past Health (Past History):
A. Childhood Illness/Immunizations:
Varicella, Influenza ~ once every winter, Vaccinations including TB, MMR,
Hepatitis B, Tdap (booster within last 10 years), Strep throat early teens, No
Pertussis, Pneumonia
B. Accidents or Injuries:
Denies any auto accidents, head injuries, burns, debilitating injuries, fractures,
penetrating wounds
C. Serious or Chronic Illnesses:
No Asthma, Depression, Diabetes, Hypertension, Heart Disease, HIV/AIDS,
Hepatitis, Sickle-Cell, Cancer, Seizures
 D. Hospitalizations and Operations:
Wisdom teeth removed (all 4) d/t pain (2013) took 800mg ibuprofen
E. Obstetric History:
N/A (Male)
F. Adult Immunizations:
No Immunizations as adult, last known childhood years
G. Last Examination Date:
Physical (2013), Dental (2014), Vision (September 2015), No other known
examinations
H. Allergies/Reactions:
No known allergies to medications, food, environmental sources, not allergic to
Latex
How would you describe your health?
“Average, not fat, not skinny, no serious health problems in past”
VI. Medications Dose Dosage Times
1. One a Day Men’s Gummies 2 per day Morning
VII. Family History (include family tree):
VIII. Social History, Culture, Religion, Education:
Bowling since 1998, Golf since 2008, NHS in high school, Lawn Care since 2011,
Bowling Alley since September 2015, Aluminum Factory (2014-2015), Slovak,
Catholic Background, Struthers High School graduate, 3rd year sophomore @
Youngstown State University expected to graduate in 2018
IX. Review of Systems:
A. General Overall Health State
Weight gain d/t stress since 2013, denies recent fatigue, weakness, malaise, fever,
chills, (night) sweats
B. Skin:
Pink and Silvery Striae on hips d/t weight gain, no Hx of skin disease including
psoriasis, hives, denies pruritus, presence of moles, lesions, bruising, rashes, uses
sunblock at the beach
C. Hair:
Denies Alopecia/hair loss and changes in texture
D. Nails:
Nail bitter, denies brittleness, and changes in shape, color
E. Head:
Denies Vertigo, Syncope, head injury, unusual/severe headaches
F. Eyes:
Glasses/Contacts d/t Nearsightedness, denies blurring, blind spots, eye pain,
Diplopia, redness/swelling, watering/discharge, no Glaucoma, Cataracts
G. Ears:
Tinnitus every day past couple years, severity fluctuates from minor annoyance to
inability to hear w/o pain (only pain if accompanied w/ ear infection), no
aggravating or alleviating factors, denies earaches, infections, discharge, Vertigo
H. Nose and Sinuses:
Denies discharge, unusual colds, sinus pain, nasal obstruction, nosebleeds,
changes in smell, no allergies or hay fever
I. Mouth and Throat:
Denies mouth pain, sore throat, gum bleeding, toothache, lesions, Dysphagia,
Hoarseness, change in voice/taste, no Tonsillectomy
J. Neck:
Denies neck pain, limitation of motion, lumps/swelling, enlarged/tender Lymph
Nodes, Goiters
K. Breast:
Denies breast pain, lumps, discharge, rashes, no Hx of disease or surgery
L. Axilla:
Denies tenderness, lumps, rashes
M. Respiratory System:
SOB after a couple flights of stairs, no Hx of lung diseases including Asthma,
Emphysema, TB, Pneumonia, Bronchitis, denies chest pain w/ breathing,
abnormal breath sounds, unusual sputum color, Hemoptysis
N. Cardiovascular System:
Denies chest pain, pressure, tightness/fullness, palpitation, Cyanosis, Dyspnea on
exertion, Orthopnea, Paroxysmal Nocturnal Dyspnea, Nocturia, Edema, no Hx of
Heart Murmur, Hypertension, Coronary Heart Disease, Anemia
O. Peripheral Vascular System:
Denies coldness, numbness/tingling, swelling/discoloration of peripheries,
Varicose Veins/complications, Intermittent Claudication, Thrombophlebitis,
ulcers
P. Gastrointestinal System:
Denies problems with appetite, food intolerance, Dysphagia, heartburn,
indigestion, pain when eating, abdominal pain, Pyrosis, nausea/vomiting (blood),
no Hx of abdominal disease, flatulence couple times a day, bowel movement ~ 2
times a day, denies stool changes including characteristic, constipation/diarrhea,
black stools, rectal bleeding, or any rectal conditions including Hemorrhoids,
Fistula
Q. Urinary System:
Frequency and urgency depends on fluid intake, “can usually hold it pretty well
though” denies Nocturia, Dysuria, Polyuria, Oliguria, hesitancy/straining
narrowed stream, incontinence, pain in flank, groin, suprapubic region, lower
back, urine color usually clear/yellow depending on fluid intake, no Hx of urinary
disease including kidney disease/stones, UTIs, prostate
R. Male/Female Genital System:
Denies penis/testicular pain, sores or lesions, discharge, lumps, Hernias
 S. Sexual Health:
In an equally satisfied sexual relationship, partner receives contraceptive shot
every 3 months with satisfaction, denies condom usage, changes in
erection/ejaculation, sexual activity with anyone who has an STI including
Gonorrhea, Herpes, Chlamydia, Venereal Warts, HIV/AIDS, Syphilis
T. Musculoskeletal System:
No Hx of Arthritis, Gout, back pain, disk disease, Joints may “crack” upon
waking up, denies joint pain, stiffness, swelling, deformity, limitation of motion,
muscle pain, cramps, weakness, gait problems, activity problems, back pain,
stiffness, limitation of motion
U. Neurologic System:
No Hx of Seizure disorder, Stroke, fainting, blackouts, Motor Function weakness,
tremor, paralysis, coordination problems, Sensory Function numbness/tingling
(Paresthesia), Cognitive Function Memory disorder, Mental Status including
mood change, depression, dysfunction, hallucinations, Occasional Tic when
“extremely nervous” d/t exams
V. Hematologic System:
Denies bleeding tendency of skin/mucous membranes, excessive bruising, Lymph
Node swelling, exposure to toxic agents/radiation, blood transfusion
W. Endocrine System:
No Hx of Diabetes, symptoms including, Polyuria, Polydipsia, Polyphagia,
Thyroid disease, denies heat/cold intolerance, change in skin
pigmentation/texture, Diaphoresis, abnormal hair distribution, tremors, need for
hormone therapy, “my appetite definitely reflects my weight”, occasional
nervousness d/t exams
X. Functional Assessment:
A. Self-Esteem/Self-Concept:
Currently enrolled in college, financial status more than adequate, no religious
practice
B. Activity/Exercise:
School, work, study, eat, sleep, bowl 6 days a week, can do everything
independently including feeding, bathing, dressing, walking, climbing stairs
C. Sleep/Rest:
Normal sleeping patterns, wake up at different times d/t priorities, naps included
D. Nutrition/Elimination:
Past 24 hours: Dinner – Los Gallos (burrito/chips), Snack – Coke, ice cream,
chips, Breakfast – smoothie, star crunch, fruit rollup, Lunch – Inner Circle (8”
pizza w/ salad), Dinner – pork chop, broccoli, mac n’ cheese, Snack – cinnamon
roll, candy, Not typical, buys/prepares food for self and partner, Soda (3 8 oz.
cans) at work
E. Interpersonal Relationships/Resources:
Denies any major roles in the family, gets along well w/ family/friends/co-
workers, talks to bowling coach about any problems, time spent alone is
“amazing” d/t busy lifestyle
F. Coping and Stress Management:
Stress d/t overwhelming amount of work/responsibilities including 3 jobs, school,
president of bowling club, in a relationship, friends, Stress coping w/ food, “quit
one job to reduce stress and free up some time which helped immensely” little
financial burden
G. Personal Habits:
Drinks alcohol “occasionally”, last drink about a month ago at a wedding and was
only a sip, 0 times in last 30 days, nobody ever said he has a drinking problem,
don’t need to cut down on drinking, only annoyed with criticisms for not
drinking, never felt guilty about drinking, never drink in the morning, denies use
of tobacco, street drugs
H. Environment/Hazards:
Lives with parents in a safe environment, w/ adequate heat and utilities,
transportation, uses seatbelts, denies hazards at work, home, neighbors
“annoying”
I. Occupational Health:
Bowling alley – easy, eat, sit, can be stressful d/t having to “deal w/ the public”,
Worked at aluminum factory w/ repetitive motion, inhalation of aluminum dust,
face mask didn’t work, no programs monitoring exposure, no problems d/t work
as of now, boss was very lenient but repetitive work wasn’t ideal