Health History Form for Recurrent Breathing Problems and Asthma

This health history form is for a patient suffering from recurrent breathing problems and asthma. It includes biographical data, health history/illness, health beliefs and practices, medications, past history, emotional history, family history, psychosocial/occupational history, ethnicity and culture, spirituality, self-concept, and review of systems.

Running head: HEALTH HISTORY FORM
Health History Form
Name of the student
Name of the university
Author note

1HEALTH HISTORY FORM
BIOGRAPHICAL DATA (15
points)
Date: 25th September, 2018
Initials: Mr J. M. Roberts
Age: 56
Date of birth: 29 May, 1962
Birthplace: Seattle, Washington D. C., USA
Gender: Male
Marital status: Married
Race: Caucasoid (White) race
Religion: Christian
Occupation: High School teacher
Health insurance: Present
Source of information: Direct interrogation.
Reliability of source of
information:
Completely reliable.
PRESENT HEALTH
HISTORY/ILLNESS (20
points)
Reason for seeking care: Recurrent breathing problems and asthma.
Health patterns: Often suffer from common cough and cold.
Health goals: Complete recovery from breathing issues and achieving
a healthy lifestyle.

2HEALTH HISTORY FORM
HEALTH BELIEFS AND
PRACTICES (15 points)
Beliefs and practices: His practices include smoking that harms his
respiratory and immune system (Ahmedani et al.,
2013).
Factors influencing healthcare
decisions:
He needs to stop smoking. Reducing the number of
cigarettes will not be able to improve his condition.
Related traits, habits or acts: Smoker since early ages. Used to be a heavy smoker.
Currently has reduced the number of cigarettes. Smokes
daily 6-8 cigarettes on an average.
MEDICATIONS (20 points)
(Please refer to your
assignment guidelines.)
Prescription medications: Budesonide and Formoterol, Albuterol (Ventolin)
(Price et al., 2013).
Over-the-counter medications: Guaifenesin, Hydrofloroalkane (HFA)
Herbals: None.
PAST HISTORY (20 points)
Childhood diseases: Asthma, food allergies, Pneumonia.
Immunizations: The common vaccinations: MMR, DTP, Polio, Hep-B,
Varicella
Allergies: Pollen allergy, allergy in dust mites, pet furs, food
allergies from peanuts and shellfish.
Blood transfusions: No
Major illnesses: None.

3HEALTH HISTORY FORM
Injuries: Bone fracture at the age of 42. Fractured right femur
bone.
Hospitalizations: Multiple times due to breathing issues, severe asthma
attacks, bone fracture, allergic reactions.
Labor and deliveries: NA
Surgeries: One surgery in the right femur bone of the leg.
Use of alcohol: Almost 2-3 times a week.
Use of tobacco: Smokes cigarettes.
Use of illicit drugs: None.
EMOTIONAL HISTORY (15
points)
Mental, emotional or psychiatric
problems:
Suffered from acute depression at the age of 34. This
happened due to loss of his first born child. Regular
therapy helped him get back to his normal life.
FAMILY HISTORY (20
points)
Father: Henry M. Roberts
Mother: Melody Roberts
Siblings: One brother: Jeremy Roberts
Grandparents: Paternal: Lucius and Eva Roberts
Maternal: Patrick and Emilia Knight
PSYCHOSOCIAL/
OCCUPATIONAL HISTORY
(15 points)
Occupational history: Worked at an insurance company for 6 years, before

4HEALTH HISTORY FORM
getting employed as a History teacher at the local High
School.
Educational level: College graduate with History Major.
Financial background: Does not want to disclose.
ROLES AND
RELATIONSHIPS (15 points)
Significant others: Spouse: Angie Roberts.
Support systems: Children: One daughter. Emma Roberts. 15 years of
age.
ETHNICITY AND CULTURE
(15 points)
Ethnicity and culture: Believes in Catholic Christian culture.
Physical and social
characteristics that influence
healthcare decisions:
He works till late at night. Does not get enough sleep.
Likes to go on small trips to mountains. This worsens
his allergic and breathing conditions (Apter et al.,
2013).
SPIRITUALITY (5 points)
Religious and spiritual needs: Catholic. Goes to church every Sunday to attend prayer.
Says it makes him feel content.
SELF-CONCEPT (5 points)
View of self-worth: Not willing to disclose.
Future plans: Improve own health. Buy a bigger house in the
neighbourhood. Send daughter off to college.
REVIEW OF SYSTEMS (25
points) (Please refer to your

5HEALTH HISTORY FORM
assignment guidelines and
Chapter 4 of your text. This is
not a physical examination.)
Skin, hair, nails: Skin: Pale
Hair: Getting bald. Baldness in men runs in family.
Nails: Normal.
Head, neck, related lymphatics: No issues identified. Although patient complained of
occasional headaches, mostly after asthma attacks.
Eyes: Dilated and redness seen.
Ears, nose, mouth, and throat: Redness and inflammation seen.
Respiratory: Breathing trouble. Thickened airways and
bronchospasm (Federman et al., 2013).
Breasts and axillae: None.
Cardiovascular: No issues.
Peripheral vascular: None.
Abdomen: Normal function.
Urinary: Normal.
Reproductive: No issues.
Musculoskeletal: Occasional pain in the back muscles.
Neurologic: No issues.

6HEALTH HISTORY FORM
References:
Ahmedani, B. K., Peterson, E. L., Wells, K. E., Rand, C. S., & Williams, L. K. (2013).
Asthma medication adherence: the role of God and other health locus of control
factors. Annals of Allergy, Asthma & Immunology, 110(2), 75-79.
Apter, A. J., Wan, F., Reisine, S., Bender, B., Rand, C., Bogen, D. K., ... & Priolo, C. (2013).
The association of health literacy with adherence and outcomes in moderate-severe
asthma. Journal of allergy and clinical immunology, 132(2), 321-327.
Federman, A. D., Wolf, M., Sofianou, A., Wilson, E. A., Martynenko, M., Halm, E. A., ... &
Wisnivesky, J. P. (2013). The association of health literacy with illness and
medication beliefs among older adults with asthma. Patient education and
counseling, 92(2), 273-278.
Price, D., Bosnic-Anticevich, S., Briggs, A., Chrystyn, H., Rand, C., Scheuch, G., ... &
Inhaler Error Steering Committee. (2013). Inhaler competence in asthma: common
errors, barriers to use and recommended solutions. Respiratory medicine, 107(1), 37-
46.