Health History

I. Date: 02/24/11

II. Identifying Data: 22 years of age, DOB 05/31/88; Born in Houston, Tx; Divorced; Full Time Student; Non-Denominational Christian.

III. Source of Referral: None

IV. Source of History: Patient

V. Chief Complaint: None

VI. Present Illness: None, No present illness.

VII. Past History: a. Patient states, “Basically healthy, I try to eat well and exercise.” b. No major illnesses. Born four weeks premature. Patient did have the Chicken Pox. Patient also had Mononucleosis as an adolescent. c. No Adult illnesses. d. General Anxiety Disorder (GAD) e. No Accidents or injuries. f. No operations. g. No hospitalizations other than hospitalized for child birth in October of 2008.

VIII. Current Health Status: a. Patient states, “adverse effects to Codeine.” Allergies also to pollen and other outdoor allergens which irritate sinuses. b. Patient has had the following immunizations: Hepatitis Series, Tdap, and Varicella. c. TB skin test negative. Pap smear- no abnormalities found. d. No environmental hazards. e. Exercises four to six times per week at 30-60 minutes each time. Exercises include both cardio and strength training. f. Patient goes to sleep with ease but awakens several times throughout the night. g. Patient states diet is as follows; “Anywhere between 1500 to 2200 calories per day. Usually eats well and attempts to abide by daily recommendations of each food group.” Daily multi-vitamin. Minimal caffeine intake. h. On a daily basis, patient takes Effexor, Trinessa, Alavert and a multi- vitamin. Patient also uses an albuterol inhaler as needed. Patient has prescription for Parfon forte and Xanax which is taken as needed and rarely. i. Does not smoke. j. Patient drinks 1-2 glasses of wine 2-3 times per week. No drug abuse. Grandfather was an alcoholic.

IX. Family History: a. Mother- 54, Hypertension, carpal tunnel, Arthritis throughout body, obesity.
Father-54, High Cholesterol. b. Patient's brother has diabetes as well as on Fathers side of family; Fathers mother, sisters and brother have diabetes.

X. Psychosocial History: a. Patient lives with daughter and sister. b. Daily activities include: School on campus or at home, workout routine, possible errand running, daily household needs and taking care of 2 year old daughter. c. Patient currently a full time student and is divorced. d. No military service. e. Worked at American General Finance as a CAS before returning to school. f. Patient is on a fixed income but is managing well at this time. g. Patient doesn’t currently participate in any recreational activities. h. Unsure of retirement plans at this time. i. Non-denominational Christian j. Optimistic view of present living and future living.

XI. Review of Systems: a. 108 lbs. Good energy level. b. No abnormalities in skin, hydrated and clear. c. No headaches or head injuries. d. Eyes clear. Wears contacts, most recent eye exam in November of 2010. e. No hearing abnormalities. f. Often has sinus trouble due to allergies. g. Healthy mouth and throat. Teeth and gums are in good condition. Routine dentist checkups. h. No abnormalities in neck. i. No abnormalities in breasts. j. Exercise induced asthma or situational asthma. k. No cardiac tests. No cardiac abnormalities. l. No gastrointestinal abnormalities. Patient has regular bowel movements. m. No urinary abnormalities. n. Menarche was at 12 years of age. Regular cycle and monthly usually lasting four days and sometimes five. Two pregnancies, one birth. Patient takes Trinessa for period regularity. Patient is divorced and is not sexually active. o. No peripheral vascular abnormalities. p. Mild scoliosis and muscle spasms in lower back. Sometimes lower back is tender and sore and sometimes it is stiff and sore. q. No hematological effects. r. No neurological abnormalities. s. No endocrine abnormalities. t. Patient has GAD (General Anxiety Disorder); takes Effexor daily and Xanax as needed.