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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….....