Current Health Status (a short statement about present state of health; provide chronological record of current health problems):
What is your current health status?
He said that he is happy with his general health. However, he has some health issues like diabetics for which he continues to take medicine and he says that it is under control
Is there anything you concern about your health?
He is concerned about his eye vision because he gets headache every time he reads Newspapers and the doctor advised for an eye checkup.
Is there anything that hurts or bothering you?
He is worried about his shoulder, because he fell on ice while he was curling and his left shoulder continues to hurt. He had an X-ray of the shoulders and his doctor said that there are no bone fractures. However, the doctor suggested an ultrasound scan of the shoulder if the pain persisted after a couple of weeks.
Past Health History (list childhood illnesses, accidents or injuries, chronic illnesses, mental health concerns, hospitalizations, operations, obstetrical history, immunizations, most recent examination dates for physical, dental, vision and hearing):
Have you had any childhood illness? No, he hadn’t.
Have you had any measles or mumps or chickenpox? He has had measles when he was 5 and got it form his siblings.
Have you had any surgeries in the past? He had Appendicectomy in his 20s.
Have you had any severe or chronic illnesses? Not that he knows of.
Did you have any mental health concerns that I should be aware of? He said once he had panic attack while he was in a closed area underground.
Do you see your dentist, and eye doctor regularly as well? He went to the dentist 3 months ago and he has an appointment with the eye doctor next month.
Any other health problems I should be aware of? He is diabetic from the age of 35 and currently it is controlled by medications.