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Outline Of A Health History

Decent Essays

HEALTH HISTORY
Date: 05/09/2015
Initials: J. B
Age: 50
Date of birth: 04/03/1946
Birthplace: Kumasi, Ghana
Gender: Male
Marital status: Married
Race: Black American
Religion: Christian
Occupation: Clerk at USPS
Health insurance: Employer provides medical, dental, and vision
Source: Primary – patient provided all information
Reliability: Reliable, alert, oriented, able to recall accurate information.

PRESENT HEALTH HISTORY/ILLNESS
Reason for seeking care Patient states his body, hands and head shakes when walking or sitting
Health beliefs and practices Patient believes health is definitely important and visits his doctor when problems persist or are troubling.
Health patterns Patient attends physical exams at least twice every year. …show more content…

He is a father of three boys.
Ethnicity and culture No specific beliefs, patient states “I consider myself to be an African and adhere to the Ghanaian culture”
Family Close relationship with all family members both in the united states and Ghana. Patient also tries to keep in touch with family often as possible.
Spirituality Roman, Catholic
Self-concept Views himself as an independent, reliable and loyal man

REVIEW OF SYSTEMS
Skin, hair, nails Skin: oily on face around nose and chin, no other abnormalities.
Nails: patient have very hard fingernails, no color

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