Shadow Health Comp Assessment
Identifying Data & Reliability -Ms. Jones
-28-year-old
-African American
-single
-religious preference
-Education
-Occupation: Smith, Stevens, Stewart, Silver & Company
-Occupational history
-woman
-presents for a pre- employment physical. -She is the primary source of the history. -offers information
freely and without contradiction.
-Mrs. Jones Reliable historian
General Survey Alert/oriented
-seated upright
-well-nourished
-well-developed
-dressed appropriately
-good hygiene.
Reason for Visit SEE HPI
history of present illness HPI: "pre-employment physical" prior to initiating employment."
Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the
past"
Medications + Fluticasone propionate 110 mcg 2 puffs BID, Metformin, 850 mg PO BID,
Drospirenone, ethinyl estradiol PO QD, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn, Acetaminophen
500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps)
-using topical antifungals, anti-itch creams, steroid topical ointments, eye/ear/sublingual drops,
Benadryl, herbs gingko/garlic/primrose.
Allergies +Penicillin (Rash), dust/cats (runny nose, itchy swollen eyes)
Identifying Data & Reliability -Ms. Jones
-28-year-old
-African American
-single
-religious preference
-Education
-Occupation: Smith, Stevens, Stewart, Silver & Company
-Occupational history
-woman
-presents for a pre- employment physical. -She is the primary source of the history. -offers information
freely and without contradiction.
-Mrs. Jones Reliable historian
General Survey Alert/oriented
-seated upright
-well-nourished
-well-developed
-dressed appropriately
-good hygiene.
Reason for Visit SEE HPI
history of present illness HPI: "pre-employment physical" prior to initiating employment."
Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the
past"
Medications + Fluticasone propionate 110 mcg 2 puffs BID, Metformin, 850 mg PO BID,
Drospirenone, ethinyl estradiol PO QD, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn, Acetaminophen
500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps)
-using topical antifungals, anti-itch creams, steroid topical ointments, eye/ear/sublingual drops,
Benadryl, herbs gingko/garlic/primrose.
Allergies +Penicillin (Rash), dust/cats (runny nose, itchy swollen eyes)
