Student Documentation Model Documentation Social History Never pregrenant Lives

Student documentation model documentation social

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Student Documentation Model Documentation Social History Never pregrenant. Lives with mother and sister, but will move to own apartment in one month. She reports that starting an accounting cleark at Smith, Stevens, Stewart, Sliver & Company in two weeks. She reports that she enjoy spends time with her firiends, her book club, talks at church, bile study, watch TV sometimes. She deneis use of recreation drungs. The last use of Marijuana was age of 20 or 21 years. She reports usual breakfast is frozen fruit smoothie with yogurt. Usual lunch is vegetable with either quinoa or brown rice with vegetables. Usual dinner is variety of chicken for diabetes recipes. Never married, no children. Lived ind currently lives with mother and sister will move into own apartment in one position in two weeks at Smith, Steve Company. She enjoys spending time attending Bible study, volunteering in Tina is active in her church and descr social support system. She states that cope with stress. No tobacco. Cannab 21. Reports no use of cocaine, metham Uses alcohol when “out with friends, reports drinking no more than 3 drink breakfast is frozen fruit smoothie wit is vegetables with brown rice or sand fat pita, dinner is roasted vegetables a sticks or an apple. Denies coffee intak diet sodas per day. No recent foreign in mild to moderate exercise four to f consisting of walking, yoga, or swim Mental Health History Denies depression, anxiety. Sleeping has been improved since last visit. Sleep 8-9 hours a night, She reports that has more energy. Pleasant Reports decreased stress and improve improved previous sleep difficulties. depression, anxiety, or thoughts of su person, place, and time. Well-groome conversation and is cooperative. Moo facial fasciculation. Speech is fluent, Review of Systems - General She reports no recent illness, no fatigue, no chills, no back pain. Weight loss around 10 pounds by eathing healthier and exercise. Well groomed, cooperative and pleasant conversation. Speech is fluent and provide own medical history. No recent or frequent illness, fatigue, sweats. States recent 10 pound weigh exercise increase. HEENT
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Student Documentation Model Documentation Subjective She denies any headache, eye problem, ear problem, nose problem. She wears eye glasses now. Denies tenderness in mouth. No dryness, sore throat, gum disease. Denies nose drainage. Denies difficulty swallow. Reports no current headache and no h acute visual changes. Reports no eye dry eyes. Wears corrective lenses. La months ago. Reports no general ear p hearing, ear pain, or discharge. Repor smell, sneezing, epistaxis, sinus pain Reports no general mouth problems, pain, sores, issues with gum, tongue, concerns, last dental visit was 5 mont swallowing, sore throat, voice change Objective Facial no discoloration. Head midline, hair distribution symmetrical, no masses papated scalp, normocephalic. Eye conjuntiva pink, no leisons. sclear is white and clear. PERRLA bilaterally. no palpablesupraclavicar lymph nodes. 2+ no thrill left and carotid. No bruit carotid. No palpable axillary lymph nodes.
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