1. Biographical Data
Marital Status: Divorced
Race/ethnic origin: American Indian
Occupation: Secretary State Park
2. Source of History- Self
3. Reason for Seeking Care- Time for annual examination. Has noticed some pain in the Right Knee.
4. History of Present Health Concern/Symptom- Pain and stiffness in Right Knee, began about 2 years ago and does not effect daily activities at this time. Pain ranges between 2-3 on a scale of 10. Uses Tylenol 500 mg 1-2 every 4 hrs when pain does not resolve with rest. No other symptoms such as fever, or weight loss or gain.
5. Past Health
Childhood Illnesses –usual childhood illnesses
Accidents or Injuries- fell of horse 1964 without major surgery
Serious or Chronic Illnesses- no major adult illnesses
Hospitalizations or Operations-Vaginal Hysterectomy 2004
Obstetric History (gravida, para, abortions) G4 P4 A0 Vaginal delivery x 4 (1973, 1976, 1979, 1988)
Immunizations- hep B vaccine series 4 years ago, Td booster 6 years ago, oral polio vaccine series in 1975
Allergies/Reactions- hay fever in spring, no food or drug allergies known
Last examination date- Pap smear and mammogram 2 months ago with no problems detected, dental exam and cleaning every 6 months, vision exam every year
Current medications- Tylenol 500mg 1-2 prn pain, Compounded Hormonal therapy
6. Family History- see genogram attached. No history of cancer, tuberculosis, respiratory, renal, thyroid, or psychiatric disorders.
7. Review of Systems
General symptoms- No fever, chills, would like to lose 15 pounds gained over the past 3 years due to inactivity and poor diet.
Skin, Hair, and Nails- Several flat nevi, no change in appearance noted, bathes daily, washes hair every other day, colored hair, nails short without color.
Head and Neck- Periodic headaches, no more than twice a month, related to tension, pain mostly in around front of head, relieved by Tylenol and...