Example of a Health History Report

Health History

1. Biographical Data

Date: 10/03/05

Examiner:

Name: . Phone:

Address:

Birth date: Birth place:

Age: 19 Sex: M Marital Status: Single Occupation: Student

Race/ethnic origin: Caucasian Employer: N/A

Health Insurance: None

2. Source and Reliability: Client himself, Seems reliable

3. Reason for Seeking Care: "Nausea, Upset stomach" Getting in the way of patients normal activity. Patient has had pain for up to 3 days now.

4. Present Health or History of Present Illness: Notices it more when he eats something. Noticed it first when he just got done eating, about 3 days ago. Not eating makes is better. And sleeping makes the patient feel better.

The severity of the pain on a scale of 1-10, patient rated it a 7.

Pain exists in the stomach, does not spread just hurts in the stomach. Pain has stayed the same for 3 days.

First noticed it after lunch 3 days ago. Patient has pain all the time but it gets worse after the patient eats.

Patient thinks this may be an ulcer of some kind.

5. Past Health:

General Health: Good

Childhood Illnesses: Chronic Bronchitis

Severe Chicken Pox

Accidents or Injuries: None

Serious or Chronic Illnesses: Bronchitis

Hospitalizations: Petersburg (Grant Memorial) Pectus Repair Surgery. Patient not sure of exact date but knows it was when he was in fifth grade.

(Garrett Memorial) Severe Stomach Flu. October 3, 1997

Operations: Pectus Repair Surgery

Obstetric History: None

Gravida: None Term Preterm

(# Pregnancies) (# Term Pregnancies) (# Preterm Pregnancies)

Ab/incomplete Children Living

(# Abortions/Miscarriages)

Course of Pregnancy

Immunizations: Hep B, Meningitis, MMR, Flu, Tetanus.

Last examination date: 09/26/05. Was told that he had severe depression. Patient was put on medication for depression.

Allergies: None Reaction: None

Current Medications: Paxil, Prevacid.

6. Family History

Specify:

Heart disease High Blood Pressure X

Stroke Diabetes X

Blood Disorders Breast Cancer X

Cancer(Other) Sickle cell

Arthritis X Allergies X

Asthma X Obesity

Alcoholism Mental Illness X

Seizure disorder Kidney Disease

Tuberculosis

7. Review of Systems

General Overall Health State: Present weight is162, patient recently lost weight, not experiencing fatigue, weakness, fever, chills, sweats or night sweats.

Skin: mole removed (the color changed on it) no history of skin disease. No other skin cooler changes have occurred.

Hair: No recent hair loss, or change in texture.

Nails: No change in shape, color or brittleness.

Head: No recent headaches, injuries, or dizziness, syncope or vertigo.

Eyes: No difficulty with