Female Health History Interview Biographical Data Born:

Female Health History Interview

Biographical Data

Born: July 15, 1961 in Denver, Colorado

Age

Gender: Female

Marital Status: Widow

Occupation: Writer

Race/Ethnic Origin: Caucasian (European)

Employer: Self-Employed

Source and Reliability: Phyllis is honest and her information is reliable

Reason for Seeking Care: She has several health issues that concern her

Present Health or History of Present Illness: She is overweight and has high blood pressure

Past Health

In general Phyllis has been healthy but she has had high cholesterol, skin cancer, a peptic ulcer, and genital herpes

Childhood Illnesses: Phyllis had measles and scarlet fever

Accidents or Injuries: she was in a serious car accident at 33; she suffered major contusions to her face, broken ribs and lacerations to her legs

Serious or Chronic Illnesses: she had scarlet fever as a child but has no after effects

Hospitalization: she was hospitalized after the car accident for three weeks

Operations: she had an abortion in her 30s

Obstetric History: she was pregnant twice; once she had a miscarriage; another time she decided to abort the fetus; she has no children

Course of pregnancies: her baby was miscarried at 15 weeks; she aborted her fetus at

12 weeks

Immunizations: smallpox, tetanus, diphtheria, pertussis

Last examination date: August, 2011

Allergies: allergic to cats, dust mites and foods that contain wheat (she needs gluten-free

foods)

Current medications: Maalox, Naproxen (for gout), Statins (for high cholesterol).

Family History: diabetes, heart disease, cancer, arthritis, allergies, obesity, drug addiction (prescription drugs), asthma

Current Health Problems:

Present weight: 60 pounds overweight

Skin: had skin cancers removed at the age of 46

Hair: ample hair on her head and is mostly gray with streaks of blonde from the hair stylist.

Nails: her nails are perfectly healthy; she uses bright red nail polish on feet and hands

Head: she has frequent headaches and an occasional hangover from excessive drinking

Eyes: she uses reading glasses for writing and computer work but otherwise has no problems with her vision

Ears: she has ringing of the ears (Tinnitus) for which she takes a vitamin supplement that does not provide any relief; she is planning to have hearing aids which her doctor told her would help with the ringing of her ears

Nose and Sinuses: there are no obstructions but she does have allergies as mentioned earlier in this report

Mouth and Throat: she has had several teeth removed due to gingivitis and she has a "partial" in her upper mouth and a "partial" in her lower mouth as well

Neck: due to the auto accident years ago she still has some pain in her neck

Breasts: she gets regular mammograms to check up for breast cancer but the only cancer she has had is skin cancer; she also performs self-examinations

Gynecologic checkups: her last gynecologic checkup was in the fall of 2012

Sexual Health: she is not in a relationship since her husband died 3 years ago although she has had romantic involvement with two men (she does not use birth control)

Functional Assessment

Self-esteem: Phyllis claims she has a good self-concept; she is a college graduate

Financially: her husband had a life insurance policy that left her with sufficient funds to keep her house and also she writes for a local weekly paper and sells journalism to regional magazines on women's resource issues

Value system: she is not in any denomination but believes in God and is spiritual

Self-care behaviors: she admits she is not exercising and is embarrassed at her obesity

Typical day: she gets up early, writes through the morning, drinks several cups of coffee, walks to the post office and back; in the afternoon she takes a nap and may write a bit more but often she gets together with a female friend for a glass of wine (two to three)

Leisure activities: she enjoys going to concerts (classical or jazz); she enjoys reading good novels (historical novels); she like to travel; she tries to attend fundraisers for environmental groups

Sleep and Nutrition: she gets 7 or 8 hours of sleep by going to bed early and getting up early; her nutritional intake is inconsistent and she admits not eating enough vegetables but she is trying to eat fruit twice a day and a big salad for lunch

Interpersonal relationships: she has relatives in Ohio and Colorado but rarely interacts with them. She enjoys being alone except for her afternoons with female friends and a glass or two of red wine

Personal Habits: She doesn't smoke tobacco but she does smoke marijuana three or four days a week; she has been smoking marijuana for the past 25 years or so, she is not sure. Her intake of wine is about 2 or 3 glasses in the afternoon and she has been known to drink beer on occasion, but never has more than two beers.

Over the last 30 days, she says she has had alcohol on 20 to 25 of those days, but never to the point of inebriation; her husband did drink to excess sometimes and she found that very uncomfortable and embarrassing.