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Client Health History Paper

In: Science

Submitted By yariddvc83
Words 3408
Pages 14
1. Date of History: September 19, 2012
2. Identifying Data
Age: 38 years old.
Sex: Male
Race: Hispanic
Birth Place: Cienfuegos, Cuba
Address: 1110 SW 154 AVE, Miami FL 33194.
Phone Number: 305 764 4934
Marital status: Married
Occupation: Software developer
Religion: Catholic
3. Source of referral and reliability: Patient himself who seems reliable.
4. Chief Complain: Patient states that he had a headache for 2 hours.
5. History of Present Illness Patient states that he had a headache for 2 hours 3 days ago. He states that pain started after working for more than 12 hours in front of the computer around 9.00 PM on September 16, 2012. The headache was localized behind his eyes. It was deep, constant and sharp that he had to stop working and went home. Patient states that computer use aggravates his headache and sleep improves it. The intensity of the headache was 8 in the scale of 0 to 10. He states that this headache was not associated with any head injury, dizziness or vertigo. It disappeared about 2 hours after he took 2 Tylenol pills of 500mg. Patient thinks this headache meant that his body was exhausted, and he needed to rest.
6. Past Medical History
General state of health: Healthy 38 years old male.
Childhood Illnesses: Patient states he had Varicella when he was 10 years old.
Adult Illness: Patient states that he had Hepatitis B at age of 24.
Psychiatric Illnesses: None
Accidents and Injuries: Patient denies having had any accident or injury.
Operations: Patient denies having being operated through his entire life.
Hospitalizations: Patient denies having being hospitalized.
7. Current Health Status
Current medications: Patient states that he does not take any prescription medication, but he takes Tylenol (500 mg) when he has a headache.
Allergies: Patient denies any allergies to medication, food, or environmental conditions.

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