Individual Client Health History and Examination
Client/Patient Initials: R.B. Sex F Age 70
Occupation of Client/Patient Retired
Health History/Review of Systems
Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications): Patient is AAOx4 eyes equal in size, response to light and accommodation; denies numbness, tingling, difficulty speaking or difficulty swallowing; accuses weakness and occasional migraines. Occasional over-the-counter medication for migraines.
Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medication): head is normo-cephalic, no lumps, no lesions, no tenderness;
Eyes ( eye pain, blurred vision, history of crossed eyes, redness/swelling, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medication): Denies eye pain, blurry vision, no crossed eyes , redness/swelling, watering or tearing. Nearsighted and wears glasses. History of cataract surgery in 2015. Goes to the doctor yearly.
Ears (earache or other pain, history of ear infection, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications): Denies any ears problem.
Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications): No deformity, nostrils patent, mucous pink: no septal deviation or perforation. Goes to dentist every six months, and has partial denture.
Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications): Skin intact, warm to touch, no clubbing or deformities, nail beds pink with prompt capillary refill and no noted bruise.
Breasts and Axilla...