HEALTH HISTORY
DO NOT ALTER THIS FORM
Patient must be 18 years or older not a family member or close friend
DEMOGRAPHICS
Name (Initials): KT Age: 63 Gender: F Marital Status:
Married
Date of Birth: 09/08/1961 Birthplace: Cho Lon, Vietnam
Address: 6335 Ambleside Drive Columbus, Ohio 43229
Race: Asian
Religion/Culture: Buddhist
Occupation: Stay at home mom
Insurance Coverage: Molina
Source of Information AND Reliability:
PRESENT HEALTH OR ILLNESS
Reason for Seeking Care: (“In quotes”)
“I am experiencing knee pain but it feels like its in-between the muscles.”
Present illness (PQRST of current illness):
P- Rest makes it better, moving around makes it worse
Q- Muscle pain, like a tightness/ achiness
R- Leg to the lower calf
S- Moderately severe
T- 2 weeks ago
Perception of Health: (chronological account of one priority health issue)
Type 2 Diabetes
Started in 09/28/2016, patient initially felt fatigue and increase urination and thought it was
a complication of the patients hypoactive thyroid caused by grave disease. After the patient
was diagnosed they did not believe that they had diabetes because their diet was not consist
of very sweet things on a regular basis. Over time the patient understood the severity of the
disease because of the potential Complications. Patient regularly checks their blood sugar
and drinks the medication.
PAST MEDICAL HISTORY
Childhood Diseases (age; measles, mumps, rubella, chickenpox, pertussis, strep throat,
rheumatic fever, scarlet fever, poliomyelitis)
Chickenpox
Immunization Dates (influenza, pneumococcal, shingles; date of last tetanus; and date and
results of last TB test)
, TDAP: 01/03/2007, 02/13/2017
Pneumococcal polysaccharide: 03/21/2013
INFLUENZA IIV4 6MO OR> FLUBARIX/FLUZONE/AFLURIA90686: , 12/8/2014.
11/13/2015, 10/14/2016,
Hep A, 2 Dose Adult
Hep B, Adult: 11/24/2023, 10/27/2023
Hepatitis B: 04/03/2023
INFLUENZA IIV4 18 YO OR > FLUBLOK QUAD 90682: 11/07/2022, 09/20/2021,
10/17/2020, 01/10/2020, 10/20/2018
INFLUENZA IIV4 6MO OR > FLUARIX/FLUZONE/AFLURIA 90686: 10/16/2023,
10/21/2017, 10/14/2016, 11/13/2015, 12/08/2014
influenza RIV3 (FLUBLOK) 18 years old or greater - syringe: 09/26/2024
Influenza TIV (IM): 11/09/2013
Moderna COVID-19 vaccine (2024-2025 12 years or older): 03/07/2025
Moderna Seasonal COVID-19 vaccine: 10/30/2023
Pfizer SARS-CoV-2 Vaccination: 12/06/2021, 04/19/2021, 03/29/2021: 11/14/2022
Pneumococcal Conjugate 20-Valent (Prevnar 20): 05/09/2022
Pneumococcal Polysaccharide (Pneumovax 23): 03/21/2013
Tdap: 02/13/2017, 01/03/2007
Typhoid Inactivated: 04/03/2023
Zoster (Shingrix): 08/02/2021, 10/17/2020
Accidents or Injuries (year; auto accidents, fractures, penetrating wounds, head trauma-
especially if associated with unconsciousness, burns; complications)
Auto Accident: 2020
Serious or Chronic Illnesses (asthma, depression, diabetes, hypertension, heart disease, HIV
infection, hepatitis, sickle-cell anemia, cancer, seizure disorder; year of diagnosis)
Hypertension, Diabetes, Hypothyroidism, Graves Disease
Hospitalizations (year; cause, name of hospital, doctor, how the condition was treated, how long
the person recovered)
Riverside Methodist Hospital: in 2015 patient complained of extreme pain after eating fish
and the doctor determined that there was gallstones and that the gallbladder needed to be
removed, patient recovered within 3 months.
Surgeries (year; type of surgery, date, name of surgeon, name of hospital, how person
recovered)
Cholecystectomy: 12/4/2015 through 12/6/2015, K WORLEY, rest and avoid foods in high
cholesterol.
DO NOT ALTER THIS FORM
Patient must be 18 years or older not a family member or close friend
DEMOGRAPHICS
Name (Initials): KT Age: 63 Gender: F Marital Status:
Married
Date of Birth: 09/08/1961 Birthplace: Cho Lon, Vietnam
Address: 6335 Ambleside Drive Columbus, Ohio 43229
Race: Asian
Religion/Culture: Buddhist
Occupation: Stay at home mom
Insurance Coverage: Molina
Source of Information AND Reliability:
PRESENT HEALTH OR ILLNESS
Reason for Seeking Care: (“In quotes”)
“I am experiencing knee pain but it feels like its in-between the muscles.”
Present illness (PQRST of current illness):
P- Rest makes it better, moving around makes it worse
Q- Muscle pain, like a tightness/ achiness
R- Leg to the lower calf
S- Moderately severe
T- 2 weeks ago
Perception of Health: (chronological account of one priority health issue)
Type 2 Diabetes
Started in 09/28/2016, patient initially felt fatigue and increase urination and thought it was
a complication of the patients hypoactive thyroid caused by grave disease. After the patient
was diagnosed they did not believe that they had diabetes because their diet was not consist
of very sweet things on a regular basis. Over time the patient understood the severity of the
disease because of the potential Complications. Patient regularly checks their blood sugar
and drinks the medication.
PAST MEDICAL HISTORY
Childhood Diseases (age; measles, mumps, rubella, chickenpox, pertussis, strep throat,
rheumatic fever, scarlet fever, poliomyelitis)
Chickenpox
Immunization Dates (influenza, pneumococcal, shingles; date of last tetanus; and date and
results of last TB test)
, TDAP: 01/03/2007, 02/13/2017
Pneumococcal polysaccharide: 03/21/2013
INFLUENZA IIV4 6MO OR> FLUBARIX/FLUZONE/AFLURIA90686: , 12/8/2014.
11/13/2015, 10/14/2016,
Hep A, 2 Dose Adult
Hep B, Adult: 11/24/2023, 10/27/2023
Hepatitis B: 04/03/2023
INFLUENZA IIV4 18 YO OR > FLUBLOK QUAD 90682: 11/07/2022, 09/20/2021,
10/17/2020, 01/10/2020, 10/20/2018
INFLUENZA IIV4 6MO OR > FLUARIX/FLUZONE/AFLURIA 90686: 10/16/2023,
10/21/2017, 10/14/2016, 11/13/2015, 12/08/2014
influenza RIV3 (FLUBLOK) 18 years old or greater - syringe: 09/26/2024
Influenza TIV (IM): 11/09/2013
Moderna COVID-19 vaccine (2024-2025 12 years or older): 03/07/2025
Moderna Seasonal COVID-19 vaccine: 10/30/2023
Pfizer SARS-CoV-2 Vaccination: 12/06/2021, 04/19/2021, 03/29/2021: 11/14/2022
Pneumococcal Conjugate 20-Valent (Prevnar 20): 05/09/2022
Pneumococcal Polysaccharide (Pneumovax 23): 03/21/2013
Tdap: 02/13/2017, 01/03/2007
Typhoid Inactivated: 04/03/2023
Zoster (Shingrix): 08/02/2021, 10/17/2020
Accidents or Injuries (year; auto accidents, fractures, penetrating wounds, head trauma-
especially if associated with unconsciousness, burns; complications)
Auto Accident: 2020
Serious or Chronic Illnesses (asthma, depression, diabetes, hypertension, heart disease, HIV
infection, hepatitis, sickle-cell anemia, cancer, seizure disorder; year of diagnosis)
Hypertension, Diabetes, Hypothyroidism, Graves Disease
Hospitalizations (year; cause, name of hospital, doctor, how the condition was treated, how long
the person recovered)
Riverside Methodist Hospital: in 2015 patient complained of extreme pain after eating fish
and the doctor determined that there was gallstones and that the gallbladder needed to be
removed, patient recovered within 3 months.
Surgeries (year; type of surgery, date, name of surgeon, name of hospital, how person
recovered)
Cholecystectomy: 12/4/2015 through 12/6/2015, K WORLEY, rest and avoid foods in high
cholesterol.
