Health History Form for Recurrent Breathing Problems and Asthma

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.