Health History Assessment Interviewee: J. H. (male) Age: 37 years old •         Demographic data – Client lives in Georgia; warm or mild to a cold climate.

Health History Assessment Interviewee: J. H. (male) Age: 37 years old •         Demographic data – Client lives in Georgia; warm or mild to a cold climate.

Health History Assessment

Interviewee: J. H. (male)

Age: 37 years old

•         Demographic data – Client lives in Georgia; warm or mild to a cold climate.

•         Perception of health – Identify exercise is beneficial for his current health which he is willing to exercise regularly on a daily basis.

•         Past medical history – He had appendectomy when he was 10.

•         Family medical history – diseases in his family include diabetes, stomach cancer, colon cancer, and hypercholesterolemia.

•         Review of systems –

GENERAL HEALTH

•         A Little fatigue, no fever, no weakness, no sweats, no recent weight change.

SKIN

•         No change in color, no rash, no lesions, no pruritus, no history of skin disease. The bruise on Lt. Index fingernail; injured during work (automobile mechanic). Hair: No loss; has some gray hair. Nails: no change.

HEAD

•         Mild headaches sometimes; had concussion 10 years ago while snowboarding; mild memory loss; MRI was normal, no syncope, no dizziness.

EYES, VISION

•         No history of eye diseases. No current eye pain, inflammation, or dryness. Wears eyeglass; farsightedness.

EARS, NOSE, MOUTH, THROAT

•         No history of ear disease, hearing loss or difficulty. No pain; no vertigo, discharge, or tinnitus.

•         No nasal discharge now; usually one to two colds per year; no sinus pain, nasal obstruction, or nasal bleeding. Has seasonal allergy; a mild runny nose and obstruction.

•         Has canker sore, No toothache, No bleeding gums, No hoarseness, No dysphagia, or No sore throat. Never had tonsillitis.

NECK

•         No pain, No swollen glands, No lumps, or No limitation of motion.

HEART, CARDIOVASCULAR

•         No chest pain, fatigue, palpitation, orthopnea, dyspnea on exertion, nocturia. No history of heart disease.

GASTROINTESTINAL

•         Little change in appetite; especially in summer. Having little indigestion problem, but on and off. No heartburn. No pain and mass in the abdomen. No nausea/vomiting. No history of gastrointestinal disease. Bowel movement 2 to 3/day, soft, brown; no rectal bleeding or pain.

MUSCULOSKELETAL

•         No pain in joints, swelling, stiffness, or limitation of motion. No history of the disease. Mild muscle pain or weakness due to work.

PERIPHERAL VASCULAR

•         No swelling in legs, pain, numbness or tingling. No history of the disease.

GENITOURINARY

•         No symptoms and history of disease and symptoms; dysuria, frequency, urgency, nocturia, hesitancy, or straining. No pain in the flank, groin.

RESPIRATORY

•         No history of respiratory disease; no chest pain with breathing; no wheezing or shortness of breath. Colds come with asthmatic symptoms sometimes; treated with prescribed steroid medicine.  Non-smoker; father and older brother are a cigarette smoker. Works in the well-ventilated workplace, but occasionally there is exhaust gas and dust from the automobile.

NEUROLOGIC

•         No history of seizure or fainting. No numbness. No mood change, depression, memory problem, or nervousness.

HEMATOLOGIC

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