Health History
Biographical Data
Patient: JT is a 69-year-old female who resides in Joliet, Illinois
Date of Birth: July 30, 1946
Occupation: retired as a data entry clerk
Marital Status: Divorced
Race: Caucasian
Religious Orientation: Roman Catholic and attends church every Sunday
Education: High School Graduate (4th Year) and graduated from a trade school where she studied data entry

Present Health Issue
Patient stated “that she has been feeling dizzy and light headed lately” She fell two days ago

Past Medical History
Patient reports that she had whooping cough and chronic ear infections at a young age, but cannot remember the exact ages. Patient reports no major accidents. Patient reported that she had Gallbladder surgery in 1976, Carpal tunnel surgery in both wrists in 2013, had bunions removed off both feet about 7 years ago and had pituitary gland surgery three time over a 10-year span. The patient cannot remember all of her immunization as a child, but does receive the flu every year for the last 20 years and received the shingles immunization in 2006. Patient went through menopause at 45 years old.

Social History
Patient lives alone. Patient has 3 sons that live with in a 30-mile radius.
Patient stated that she is lonely at times and is currently taking medication for depression.
Patient stated, “she does not have thoughts of hurting herself”
Patient ambulates without any assistance. Patient does drive and wears a seat belt
Patient does not use tobacco, alcohol, illicit drugs. Patient states that she does have 1-2 glasses of wine a week.
Patient sleeps about 7 hours a night, but gets up for frequent bathroom visits.
Patient does get out a couple times a week for breakfast and dinner with friends.
Patient has not traveled outside of the United States

Family History
Patient's Dad died of heart attack at the age of 65, mom