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Comprehensive Health History JMP.pdf - COMPREHENSIVE HEALTH...

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COMPREHENSIVE HEALTH HISTORY FORM*DO NOT INCLUDE FOR SCHOOL ASSIGNMENT; DRAW A LINE THROUGH SPACE.NAME (INITIALS) __________J.M.P.________________ GENDER______Male______________DATE___09/07/22__________________DATE OF BIRTH*/AGE_______________/___26__________BIRTHPLACE*_______________________________________________ADDRESS*_______________________________________________________________ PHONE*______________________________OCCUPATION _________Store Operator for family business _________ EDUCATION_______High School Diploma__________________INSURANCE ____________Currently uninsured______________________________ID#*_________________________RACE(S)_________White_____________ETHNICITY(IES)____________Hispanic_______________________________RELIGION__________Catholic_______________________PREFERRED LANGUAGE________English___________MARITAL STATUS_______Single__________________SPOUSE (INITIALS)_________________________________________REASON FOR SEEKING CARE (OR CHIEF COMPLAINT; USE QUOTATION MARKS)_________“I’m here because I have a “bad”cough, and highfevers__________________________________________________________________CURRENT HEALTH (OR HISTORY OF PRESENT ILLNESS)__________Reports that general health is “great.” No history of previousillnessesreported______________________________________________________________________________________________MEDICAL HISTORY√ IF POSITIVEIF NEGATIVEREMARKS(INCLUDE DATES)INCLUDE DATESILLNESSES______Reports no previous illnesses__________________________INJURIES/ACCIDENT __Reports no previous injuries/accidents_________________________HOSPITALIZATIONS _________Reports no previous hospitalizations _____SURGERIES________ Wisdom teeth removal 22 yrs old________________________ALLERGIES/SENSITIVITIES (HIGHLIGHT IF PRESENT)______Denies having any allergies orsensitivities______________________________________________________________PUBERTYMENARCHE/SPERMARCHE_______10 years old_________________________MENSTRUAL HISTORYLMP_________________ X _______DAYSPMP________________X_______DAYSINTERVAL EVERY_______________DAYSDURATION X __________________DAYSSEXUAL HISTORY______In a long-term relationship with fiancée, healthy sexual intercourseseveral times a month_________________________________CONTRACEPTIVE HISTORY (INCLUDING PRESENT)_____Use of contraceptives on occasion______STD PROTECTION__Use of condoms as a contraceptive and STD protection______________REPRODUCTIVE HISTORY PARA (TPAL)________0______________________________# OF CHILDREN___0___________________________________________________#DATESITEDELIVERYTYPEGENDERWEIGHTGESTATIONINWEEKSOUTCOMECANCER (SPECIFY TYPE)-KIDNEY DISEASE-HEART DISEASE-HYPERTENSION-PERIPHERAL VASCULAR DISEASE-RHEUMATIC FEVER-DIABETES-PULMONARY DISEASE-GALLBLADDER/LIVER DISEASEGASTROINTESTINAL DISEASE-THYROID DYSFUNCTION-THROMBOEMBOLIC PHENOMENON-CONVULSIVE DISORDER-MENTAL DISORDER-SEXUALLY TRANSMITTED DISEASE-ARTHRITIS-HEADACHE-BLOOD DYSCRASIA-ANEMIA-RUBELLA-RUBEOLA-VARICELLA03/1999MUMPS-SCARLET FEVER-OTHER HEALTH CONDITIONS e.g., GENETIC-MEDICATION HISTORY (INCLUDE Rx, OTCs, VITAMINS, HERBS, RECREATIONAL)______Use of OTCS and ibuprofen to control present and past symptoms. Denies useof vitamins, herbs and recreational____________________IMMUNIZATIONS (CARD AVAILABLE : CIRCLE YES/NO)________________Reports to be up-to-date with his immunizations__________________________

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