Course Project Milestone 1: Health History Form
Your Name: Date:
BIOGRAPHICAL DATA (10 pts) Date: 19th, November, 2013
Age: 56 years
Date of birth: 12th November, 1957
Marital status: Married
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