Examiner: Norman Jones
Initials G.H. Phone (443) 234-XXXX
Address 338 Logan Ct. Abingdon, MD
Birth date 6/4/85 Birthplace Greensboro, NC
Age 27 Gender M Marital Status Single Occupation: Accountant
Race/ethnic origin African American Employer Frank Hajek & Associates
2.Source and Reliability Client himself, reliable
3.Reason for Seeking Care Muscle soreness, fatigue, headache and fever for 3 hours
4.Present Health or Health of Present Illness:
Started to feel fatigue and a consistent radiating pain in his joints during work while sitting at his desk 3 hours ago at 3 p.m. Says on a pain scale of 10 the radiating pain is a 3 took 500mg Bayer aspirin 2 hours ago to alleviate some pain. Has difficulty holding head up for more than 10 minutes and symptoms worsen when walking or standing.
5. Past Health
Describe General Health: I’m healthy and active
Childhood Illnesses: Asthma that subsided by age 10
Accidents or Injuries (include age) Broken wrist from bicycle fall at age 14
Serious or Chronic Illnesses (include age) None
Hospitalizations (what for? Location) Broken wrist, John Hopkins Hospital, Wrist was casted, outpatient procedure, Dr. John Anik
Operations (name procedure, age) None
Obstetric History: Gravida N/A Term N/A Preterm N/A (# Pregnancies) (# Term pregnancies) (# Preterm pregnancies)
Ab/incomplete N/A Children living NONE (# Abortions/Miscarriages)
Course of pregnancy N/A
(Date delivery, length of pregnancy, length of labor, baby’s weight and sex, vaginal delivery/cesarean section, complications, baby’s condition)
Immunizations Measles-mumps-rubella, Polio, diphtheria-pertussis-tetanus 3/06, human papilloma virus 6/12, tuberculosis skin test 6/12
Last examination date Physical 6/12
Allergies Shell Fish Reactions difficulty breathing, itching throat, facial swelling
Current medications None
6.Family History – Specify
Heart disease Yes/Grandfather Allergies Shellfish/Dad
High blood pressure None Asthma Yes/Aunt/Mom
Stroke None Obesity None
Diabetes Yes/Grandmother Alcoholism or drug addiction Yes/Uncle
Blood disorders None Mental illness None
Breast /ovarian cancer None Suicide None
Cancer (other) None Seizure disorder None
Sickle Cell None Kidney disease None
Arthritis None Tuberculosis None
Construct Genogram below.
7.Review of Systems
(Circle both past health problems that have been resolved and current problems, including date of onset). (Describe circled items)
General Overall Health State: Present weight (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats or night sweats.
Skin: History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion.
Hair: Recent loss, change in texture.
Nails: Change in shape, color, or brittleness. Health Promotion: Amount of sun exposure, method of self-care for skin and hair.
Head: any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigo.
Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma, or cataracts. Health Promotion: Wears glasses or contacts; last vision check or glaucoma test; how coping with loss of vision if any.
Ears: Earaches, infections, discharge and its characteristics, tinnitus or vertigo. Health Promotion: Hearing