Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. ( add if pt is happy? , add sexual history with BF, ) Born SF, grew up in Korean towen. Widow married 50 yrs. Jennifer lawyer, tim son director. Retired nurse working at a rehabilitation clinic. Hobbies include gardening, walking a lot. Water aerobics 2-3 times a week. Started Pilates recently for exercise. Lives with daughter Jennifer with good relationship, daughter is driver. Widow but has a significant other. Denies history or present tobacco use. Reports first alcoholic drink on 13 th birthday. Drinks one glass of white wine every Sunday filled in a normal glass of wine. Avoids caffeinated drinks but ocassinally has chamomille tea. -Reports only drinking 2 glasses of water daily, reports typical meal is toast or banana or peach for breakfast, skips lunch, and dinner is a protein with rice. Reports vegetable intake every other day. Reports usually has a bowel movement every day or every other day. Reports diarrhea episode prior to being constipated for the last 5 days. ( ask depression, 24hr diet recall, enjoys food in her culture.) Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Father:Deceased at age 82, obesity, hx Heartburn, HTN, hypercholesterolemia Mother:Deceased at 88, hx of HTN and DM 2. Maternal grandparents: CAD, DM2, HTN Paternal grandparents: hx obesity, CVA , HTN Husband:passed away at 82 yrs old from a fall, resulting in brain hemorrhage Brother(Christopher)81yr old – prostate cancer, HTN, hypercholesterolemia. Brother (Michael) 80 -HTN Daughter ( Jennifer)-age 46- healthy Son 48- healthy (Add if history of colon cancer? Denies family colon ca history.) Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details.
Constitutional Skin HEENT ☒ Fatigue less energy for past week. ☐ Weakness denies ☐ Fever/Chills denies ☐ Weight Gain denies ☒ Weight Loss reports “ I don’t think so” ☐ Trouble Sleeping denies ☐ Night Sweats denies ☐ Other: Click or tap here to enter text. ☐ Itching denies ☐ Rashes denies ☐ Nail Changes denies ☒ Skin Color Changes flushed face (cheeks) ☒ Other: Reports Occassional dryness ☐ Diplopia denies ☐ Eye Pain denies ☐ Eye redness denies ☐ Vision changes denies ☐ Photophobia denies ☐ Eye discharge denies ☐ Earache denies ☐ Tinnitus denies ☐ Epistaxis denies ☐ Vertigo denies ☐ Hearing Changes denies ☐ Hoarseness denies ☐ Oral Ulcers denies ☐ Sore Throat denies ☐ Congestion denies ☐ Rhinorrhea denies ☐ Other: Click or tap here to enter text.
You've reached the end of your free preview.
Want to read all 9 pages?
- Fall '15