Course Project Milestone 1 Health History Form

Course Project Milestone 1: Health History Form

Your Name: Date:

BIOGRAPHICAL DATA (10 pts) Date: 19th, November, 2013

Initials: M.W.O.

Age: 56 years

Date of birth: 12th November, 1957

Birthplace: Michigan

Gender: Female

Marital status: Married

Race: Spanish

Religion: Christian

Occupation: Teacher

Health insurance: Has a life policy with the United health care insurance company.

Source of information: Interview with a patient at John Hopkins hospital

Reliability of source of information: Very reliable

PRESENT HEALTH HISTORY/ILLNESS (15 pts) Hospitalized for suffering yet another heart attack

Reason for seeking care: The patient suffers from hypertension

Health patterns: She has had diabetes and eye problems since childhood, She became alcoholic at 17, At the age of 20 she suffered chest pains due to obesity, at the age of 30 she suffered from a heart attack,

Health goals: She intends to completely eliminate her crave for consuming alcohol, she also intends to avoid fatty foods and heavy carbohydrates at all costs.

HEALTH BELIEFS AND PRACTICES (15 pts) She has since started dieting in order to cut her weight, she enrolled in a rehabilitation center to cut her consumption if alcohol, She goes to the gymnasium for exercises to cut on her weight.

Beliefs and practices: She beliefs in avoiding eating disorders for a healthy living. She practices this by taking milk in all her diets and avoids snacks and food with high calories at all costs.

Factors influencing healthcare decisions: The factors influencing her health care decisions include: her over weight problem and the development of heart complications.

Related traits, habits or acts: She goes for regular medical checkups, She checks her diet, She has decided to avoid alcohol and tobacco related products apart from that she is also monitoring her weight.

MEDICATIONS (15 pts) She takes both prescription medications and over the counter medications.

Prescription medications: Her prescription medications are: receptor blockers, angiosdiuretics and beta blockers.

Over-the-counter medications: Calcium channel blockers and ACE inhibitors.

Herbals: She uses anti ace peptides

PAST HISTORY (15 pts) Childhood diseases: She was diabetic when she was still seven years old

Immunizations: She was immunized against measles and malaria

Allergies: She is allergic to irritants and hidden allergens

Blood transfusions: She has had two blood transfusions

Major illnesses: Her major illness is heart failure

Injuries: She injured her elbow while playing basketball

Hospitalizations: She has been hospitalized 20 times

Labor and deliveries: Her two labor and deliveries were done through caesarian section

Surgeries: She has had one surgery to remove a brain tumor when she was a kid

Use of alcohol: She was alcoholic but has since changed

Use of tobacco: She used tobacco when she was alcoholic but has since changed

Use of illicit drugs: She used illicit drugs while she was alcoholic but has since changed

EMOTIONAL HISTORY (15 pts) Mental, emotional or psychiatric problems: She has no history of Mental, emotional or psychiatric problems

FAMILY HISTORY (15 pts) Father: Was alcoholic

Mother: Experienced heart problems in her old age

Siblings: Two are alcoholic while one is diabetic

Grandparents: Were both alcoholic

PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts) Occupational history: She is a teacher by profession

Educational level: She has a bachelor’s degree in education

Financial background: She is well endowed economically given that she comes from a rich family

ROLES AND RELATIONSHIPS (15 pts) Significant others: Her husband is not alcoholic

Support systems: Given that husband is not alcoholic he supports her in her rehabilitation efforts

ETHNICITY AND CULTURE (10 pts) Ethnicity and culture: She is Spanish and loves football.

Physical and social characteristics that influence healthcare decisions: Her mother and husband support her efforts to reform since they are not alcoholic

SPIRITUALITY (5 pts) Religious and spiritual needs: She is a Pentecostal Christian and always visits her pastor for prayers

SELF-CONCEPT (5 pts) View of self-worth: She is a valuable teacher and her students love her

Future plans: She intends to get into the family business upon retiring from teaching

REVIEW OF SYSTEMS (20 pts) Skin, hair, nails: She has a skin rush, she has experienced hair loss, color bands can be seen under her nails,

Head, neck, related lymphatics: There is a pounding sensation in her head, and experiences neck pains

Eyes: She has been diagnosed to be having retinopathy, she also has blood spots in her eyes

Ears, nose, mouth, and throat: She experiences dizziness in her ears, her nose becomes stuffy if she catches a cold, she has lost her sense of taste, she also has an extra tissue behind her throat.

Respiratory: She experiences respiratory failures

Breasts and axillae: Her breasts and axillae are not well constructed

Cardiovascular: She has an irregular heartbeat and an enlarged heart

Peripheral vascular: She has a reduced supply of blood to her body organs

Abdomen: She experiences abdominal aortic aneurysms

Urinary: She has dark urine

Reproductive: She is not reproductive

Musculoskeletal: She has an increased level of uric acid in her blood

Neurologic: She suffers from corticobasal degeneration which is a Neurologic disorder