Father 40 year white male with no known health problems Social History complete

Father 40 year white male with no known health

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Father: 40-year- white male with no known health problems. Social History (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Cu r r e n t li vi n g s it u a t io n / p-a r t n e r / m a r i t a l s t a t u s : Lives at home with mother and father. This is their first child. E d uc a t io nal le v e l (as appropriate) : NA O cc up a t i on a l h i s t o r y (as appropriate) : NA S u b s t an ce u s e / ab u s e (ETOH, tobacco, and marijuana): NA Firearms in home: No guns in home. S a f e ty s t a t u s : Parents are using car seat, have not had infant around large crowds, infant sleeps on back in crib, does practice safety as infant can roll over now, smoke and carbon monoxide detector in home, child safety locks on cabinets REVIEW OF SYSTEMS (Do not omit any body system & remember this is a child not an adult) General: Mother denies fever and fatigue, decreased appetite. Denies difficulty sleeping, chills, malaise, night sweats, unexplained weight loss or weight gain. Cardiovascular: Mother denies chest pain, palpitations, PND, orthopnea, edema Skin: Mother denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory: Mother denies cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB Head: Mother denies headaches, concussions, unusual head shape Breast: Mother denies lumps, bumps or changes Eyes: Mother denies corrective lenses, blurring, visual changes of any kind Gastrointestinal: Mother denies abdominal pain, N/V/D. Denies constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools Ears: Mother denies ear pain, hearing loss, ringing in ears, discharge Musculoskeletal: Mother denies back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Nose/Mouth/Throat: Mother denies sinus problems, sore throat, dysphagia, nose bleeds or discharge, dental disease, hoarseness Neurological: Mother denies syncope, seizures, transient paralysis, weakness, paresthesia, black out spells Genitourinary/Gynecological: Mother denies urgency, frequency burning, change in color of urine . Heme/Lymph/Endo: Mother denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx Revised 5/9/18; 8/9/18; 10/29/18
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Pediatric SOAP Note Developmental Problems: Mother denies any developmental problems Behavioral Status/Psychiatric: Mother denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Revised 5/9/18; 8/9/18; 10/29/18
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Pediatric SOAP Note OBJECTIVE ( Attach growth chart with height/weight/head circumference plotted & noting percentiles; attach these forms at the end of your SOAP note; include pertinent positives & negatives ) Weight: 17 lbs Temp: 98.1 BP: not measured Height: 27 in Pulse 120 Respirations: 38
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