Does not play sports.
Travels for leisure and attends church weekly.
Activity Level: Patient able to ambulate freely without the use of assistive devices as tolerated, has full range of
motion to bilateral upper and lower extremities.
Patient does not exercise.
Family History:
Relationship
Living or Deceased
Age
Illnesses
Mother
Living
40
None
Father
Living
40
None
Sister
Living
20
None
Brother
Living
19
None
Paternal Grandmother
Living
61
Diabetes
Paternal Grandfather
Deceased
58
Stroke
Preventative Health/ Anticipatory Guidance: (Age Appropriate)
1. Safety Issues: Works in healthcare which requires heavy lifting, pushing, and pulling at times.
2. Screenings: None
3. Immunizations: Flu Vaccination 2023, Covid Vaccination and Booster 2022
Reproductive health:
LNMP: 11/01/2023
First day of menarche: Age 14
Gravidity 0
Denies history of STI’s. Is not currently sexually active, 1 partner previously.
Maternal Grandmother
Living
Hypertension, Hyperlipidemia
Maternal Grandfather
Living
Hypertension, Hyperlipidemia
Preference of partner is male.
Uses condoms as contraceptive when sexually active.
Denies libido issues.
Review of Systems:
General: Denies fever, chills, low energy, or troubling sleeping. Denies recent illness, or frequent illness. Denies weight
loss/gain, appetite changes. Eats approximately 3 meals per day with snacks in between meals. Denies weakness and
fatigue.
Skin, Hair, Nails: Skin is free of lesions, rashes, and s/s of infection. Hair is present and appropriately placed. Capillary
refill < 3 seconds, nailbed without visual deformities. No color changes, sores, pain or pruritis noted. No hemorrhages
noted.
HEENT
Head: Denies history of head injury, denies lightheadedness, headaches, and migraines.
Eyes: Denies eye pain, dry eyes, and blurry vision/eye changes. Patient does not wear corrective lenses. Last eye exam
2023. No history of cataracts and denies diplopia.
Ears: Denies general ear problems, changes in hearing, ear pain and ear discharge.
Nose: Denies change in sense of smell, denies nasal or sinus pressure; denies frequent nose bleeds. Patient denies
rhinorrhea, sinus drainage.
Throat: Denies lymph node problems, voice changes, hoarseness, tonsils intact. Denies general neck pain sore throat,
swollen glands.
Denies general mouth problems, change in sense of taste, dry mouth, gum problems, tongue, and jaw problems. No jaw
clicking noted during assessment, patient denies jaw pain.
Patient has his natural teeth. Denies current dental problems. Denies current dental pain. Hx of cavities which have been
filled. No missing teeth.
Cardiovascular: Denies chest pain or discomfort. Denies palpitations, irregular heartbeat circulation and vascular
problems. No pedal edema, cyanosis.
Breast: Patient denies discharge or pain from breast. No enlargement noted, no lesions or galactorrhea.
Pulmonary: No lung issues noted. No use of ancillary muscles; denies cough, congestion, and wheezing. Patient denies
current breathing problems, has a history of childhood asthma but has since resolved. Patient denies current chest
tightness and pain while breathing. No history of TB, COPD, or pleuritic pain. Patient without tachypnea, no history of
bronchitis, denies shortness of breath, denies sputum production, and denies hemoptysis.
Abd/GI: Denies nausea, vomiting, stomach pain, changes in bowel. Patient denies heartburn, GERD. Last bowel
movement 11/12/2023, brown in color; formed and soft. Denies diarrhea, constipation flatulence and bloating. Denies
abdominal pain. Denies hemorrhoids. No history of anorexia, patient denies dysphagia, denies hematemesis, denies
clay-colored stools, denies hematochezia, denies melena; no jaundice noted during assessment.