CHAPTER 4 The Complete Health Hist02ory 29 Name

WRITE-UP—HEALTH HISTORY

Biographic Data
Name: Subodh Adhikari_____________Phone 913 6038392_________
Address: 5220 W 158th Pl, Overland Park, KS 66224 _______________________
Birthdate 08/28/1977 _________________________
Birthplace ______________Nepal_________________ Age ____41______ Gender _M_______
Marital Status _Married __________ Occupation _______________ Race/ethnic origin
__________________________________ Employer ________________________ Source and
Reliability Reason for Seeking Care Present Health or History of Present Illne

Past Health

Describe general health ______________Good________________________________________

Childhood illnesses _None_______________________________________________________________
Accidents or injuries (include age) ______________________________________________________
Serious or chronic illnesses (include age) ________________________________________________
Hospitalizations (what for? location?) ____________________________________________________
Operations (name procedure, age) ______________________________________________________
Obstetric history: Gravida ____________ Term ____________ Preterm ____________

(# Pregnancies) (# Term pregnancies) (# Preterm pregnancies)

Ab/incomplete _______
UNIT I Assessment of the Whole Person Course of
pregnancy__________________________________________________________________
(Date delivery, length of pregnancy, length of labor, baby’s weight and sex, vaginal delivery or
cesarean section, complications, baby’s condition)
Immunizations__________________________________________________________________
___ Last examination
date________________________________________________________________ Allergies
_________________________________ Reaction __________________________________
Current medications
_________________________________________________________________
______________________________________________________________________________
___ _ 6. Family History—Specify Which Relative(s) Heart
disease___________________________ High blood pressure______________________
Stroke_________________________________ Diabetes_______________________________
Blood disorders_________________________ Breast or ovarian cancer___________________
Cancer (other)__________________________ Sickle cell______________________________
Arthritis_______________________________ Allergies_______________________________
Asthma _______________________________ Obesity________________________________
Alcoholism or drug addiction ______________ Mental illness ___________________________
Suicide ________________________________ Seizure disorder ________________________
Kidney disease __________________________ Tuberculosis ____________________________
Construct genogram below.