Female Health History Interview Biographical Data Born: Essay

Female Health History Interview

Biographical Data

Born: July 15, 1961 in Denver, Colorado

Age

Gender: Female

Marital Status: Widow

Occupation: Writer

Race/Ethnic Origin: Caucasian (European)

Employer: Self-Employed

Source and Reliability: Phyllis is honest and her information is reliable

Reason for Seeking Care: She has several health issues that concern her

Present Health or History of Present Illness: She is overweight and has high blood pressure

Past Health

In general Phyllis has been healthy but she has had high cholesterol, skin cancer, a peptic ulcer, and genital herpes

Childhood Illnesses: Phyllis had measles and scarlet fever

Accidents or Injuries: she was in a serious car accident at 33; she suffered major contusions to her face, broken ribs and lacerations to her legs

Serious or Chronic Illnesses: she had scarlet fever as a child but has no after effects

Hospitalization: she was hospitalized after the car accident for three weeks

Operations: she had an abortion in her 30s

Obstetric History: she was pregnant twice; once she had a miscarriage; another time she decided to abort the fetus; she has no children

Course of pregnancies: her baby was miscarried at 15 weeks; she aborted her fetus at

12 weeks

Immunizations: smallpox, tetanus, diphtheria, pertussis

Last examination date: August, 2011

Allergies: allergic to cats, dust mites and foods that contain wheat (she needs gluten-free

foods)

Current medications: Maalox, Naproxen (for gout), Statins (for high cholesterol).

Family History: diabetes, heart disease, cancer, arthritis, allergies, obesity, drug addiction (prescription drugs), asthma

Current Health Problems:

Present weight: 60 pounds overweight

Skin: had skin cancers removed at the age of 46

Hair: ample hair on her head and is mostly gray with streaks of blonde from the hair stylist.

Nails: her nails are perfectly healthy; she uses bright red nail polish on feet and hands

Head: she has frequent headaches and an occasional hangover from excessive drinking

Eyes: she uses reading glasses for writing and computer work but otherwise has no problems with her vision

Ears: she has ringing of the ears (Tinnitus) for which she takes a vitamin supplement that does not provide any relief; she is planning to have hearing aids which her doctor told her would help with the ringing of her ears

Nose and Sinuses: there are no obstructions but she does have allergies as mentioned earlier in this report

Mouth and Throat: she has had several teeth removed due to gingivitis and she has a "partial" in her upper mouth and a "partial" in her lower mouth as well

Neck: due to the auto accident years ago she still has some pain in her neck

Breasts: she gets regular mammograms to check up for breast cancer but the only cancer she has had is skin cancer; she also performs self-examinations

Gynecologic checkups: her last gynecologic checkup was in the fall of 2012

Sexual Health: she is not in a relationship since her husband died 3 years ago although she has had romantic involvement with two men (she does not use birth control)

Functional Assessment

Self-esteem: Phyllis claims she has a good self-concept; she is…