Medical History Report
Medical History Report
Patient Information
-
Name: [Patient's Name]
-
Date of Birth: [Patient's Birthdate]
-
Gender: Male
-
Address: [Patient's Address]
-
Phone Number: [Patient's Contact Number]
-
Email: [Patient's Email]
1. Medical History
-
Past Medical History:
-
Hypertension: Diagnosed in March 2060; patient currently manages this condition through lifestyle modifications and medication.
-
Appendectomy: Underwent surgery in April 2060 due to acute appendicitis; no complications noted post-surgery.
-
Seasonal Allergies: Diagnosed in May 2060 with symptoms exacerbated during spring and fall; managed with over-the-counter antihistamines.
-
-
Current Medications:
-
Lisinopril: 10 mg, taken once daily for hypertension management.
-
Cetirizine: 10 mg, taken as needed for allergy symptoms.
-
Aspirin: 81 mg, taken once daily as a preventive measure for cardiovascular health.
-
Multivitamin: Daily supplement for general health maintenance.
-
-
Allergies:
-
Penicillin: Experienced rash upon administration.
-
Latex: Reports itching and redness upon contact.
-
No known food allergies.
-
2. Family History
-
Father:
-
Heart disease diagnosed in 2060; passed away in 2060 from a heart attack.
-
-
Mother:
-
Diagnosed with type 2 diabetes in 2060; currently managing with medication and lifestyle changes.
-
-
Siblings:
-
Sister: Asthma diagnosed in 2060; uses an inhaler as needed.
-
Brother: No significant medical history; active and healthy.
-
3. Social History
-
Occupation:
-
Software Developer at Tech Innovations Inc. since 2060.
-
-
Lifestyle Factors:
-
Tobacco Use: No history of tobacco use.
-
Alcohol Use: Consumes alcohol occasionally, approximately 1-2 drinks per week.
-
Illicit Drug Use: Denies any use of illicit drugs.
-
Physical Activity Level: Engages in regular exercise 4-5 times per week, including jogging (30 minutes) and cycling (1 hour).
-
4. Review of Systems
-
General:
-
No recent weight changes; reports occasional fatigue but attributes it to work stress.
-
-
Cardiovascular:
-
Denies chest pain; reports mild palpitations during strenuous exercise.
-
-
Respiratory:
-
Experiences occasional cough during allergy season; no reports of shortness of breath or wheezing.
-
-
Gastrointestinal:
-
Experiences occasional heartburn, particularly after large meals; no reports of nausea or vomiting.
-
-
Genitourinary:
-
No changes in urination patterns; denies any discomfort or pain.
-
-
Musculoskeletal:
-
Reports occasional joint pain in knees after prolonged running; no swelling or redness noted.
-
-
Neurological:
-
Experiences occasional headaches, especially during stressful periods; no episodes of dizziness or fainting.
-
-
Psychiatric:
-
Reports mild anxiety related to work pressures but no depressive symptoms; manages anxiety through relaxation techniques and exercise.
-
5. Immunization History
-
Influenza Vaccine: Received annually since 2060; last administered in October 2060.
-
Tetanus-Diphtheria: Last received in March 2060; due for a booster in March 2070.
-
COVID-19 Vaccination: Completed full vaccination series in March 2060; received booster in November 2060.
-
Shingles Vaccine: Administered in June 2060; no adverse effects.
6. Additional Notes
-
Recent laboratory tests conducted in September 2060 show:
-
Cholesterol Levels: Total cholesterol 180 mg/dL; HDL 60 mg/dL; LDL 100 mg/dL—within normal limits.
-
Blood Sugar Levels: Fasting glucose 90 mg/dL—normal.
-
-
Patient has scheduled a routine physical examination for December 15, 2060, including a complete blood panel.
-
Advised to maintain a balanced diet and continue regular exercise to support overall health.
Signature:
[Patient's Name]