1 PATIENT HISTORY FORM Identifying Data Patient Initials E.R. City/State Los Angeles, California DOB April 14, 1985 Age 30 Gender Female Race/Ethnicity Hispanic Marital Status Single Children 2 males age 5 and 10 Occupation Stay home mother Chief Complaint “I am experiencing migraines for the last week”. History Of Present Illness Sharp and throbbing pain at the frontal and occipital of head for the past 7 days. Pain comes and goes with pain scale of 7 out of 10. Pain worsens by stress and thoughts of her grandparents passing. Pain is relieved when she takes Ibuprofen 800mg and naps. Past Medical History Childhood Illnesses Chicken pox at 5 years of age without complications. Denies measles, german measles, mump, whooping cough, rheumatic fever or scarlet fever, and polio. Immunizations Flu vaccine 2015, tetanus 2014, pertussis 2014, diphtheria 2014. Doesn’t remember the dates for measles, german measles, mumps, hepatitis a&b, and pneumococcal. Adult Illnesses Migraines for the past 8 years and currently being seen by Rosales, PA at Family Care Specialist Medical Group. Asthma for the past 21 years and currently being seen by Rosales, PA at Family Care Specialist Medical Group. Never been hospitalized for these illnesses. Psychiatric Illnesses Denies any psychiatric illness. Surgical History Denies history of surgeries. Trauma, Injuries or Accidents MVA in 2013 (rear ended) in Los Angeles and was rx NSAID for neck/body pain. Obstetric History (female only) G:3 (history of 1 induced abortion), P:2 (both are males NSVD without complications during pregnancy). Transfusion History Denies history of transfusions. Current Health Status Medications Amitriptyline HCL 25mg PO QD at night. (Started: April 2014, Classification: Analgesics, Mechanism of action: Inhibits norepinephrine and serotonin reuptake, Adverse reactions: Hypotension- orthostatic, htn, syncope, Side effects: Drowsiness, dizziness, constipation, Special related tests: serum drug levels, ecg, and in peds bp and hr. Taking medication as directed without any assistance (Epocrates, 2015). ProAir HFA 90 mcg PO 2 puffs q4h (inhalant) PRN. (Started: at the age of 21 years old, Classification: Beta-2 agonists 1: short acting inhalant, Mechanism of action: Selectively stimulates beta-2 adrenergic receptors, relaxing airways smooth muscle, Adverse reactions: Bronchospasm- paradoxical, anaphylaxis, hypersensitivity, arrhythmia, Side effects: Cough, bad taste, nausea, headache, throat irritation. Taking medication as directed without any assistance (Epocrates, 2015). Ibuprofen 800mg PO q8h PRN. (Started: 2010, Classification: Analgesics/NSAID, Mechanism of action: Inhibits cyclooxygenase, reducing prostaglandin and thromboxane synthesis, Adverse reactions: GI bleeding, GI perforation/ulcer, MI, strokes, Side effects: nausea, dizziness, constipation, tinnitus, Special related tests: CBC, chemistry profile if long-term tx; BP; s/sx hepatic impairment in peds. Taking medication as direc.

1. 1
PATIENT HISTORY FORM
Identifying Data
Patient Initials E.R.
City/State Los Angeles, California
DOB April 14, 1985
Age 30
Gender Female
Race/Ethnicity Hispanic
Marital Status Single
Children 2 males age 5 and 10
Occupation Stay home mother
Chief Complaint
“I am experiencing migraines for the last week”.
History Of Present Illness
Sharp and throbbing pain at the frontal and occipital of head for
the past 7 days. Pain comes and goes with pain scale of 7 out of
10. Pain worsens by stress and thoughts of her grandparents
passing. Pain is relieved when she takes Ibuprofen 800mg and
naps.
Past Medical History
Childhood Illnesses Chicken pox at 5 years of age without
complications. Denies measles, german measles, mump,
whooping cough, rheumatic fever or scarlet fever, and polio.
Immunizations Flu vaccine 2015, tetanus 2014, pertussis 2014,
diphtheria 2014. Doesn’t remember the dates for measles,
german measles, mumps, hepatitis a&b, and pneumococcal.
Adult Illnesses Migraines for the past 8 years and currently
being seen by Rosales, PA at Family Care Specialist Medical
Group. Asthma for the past 21 years and currently being seen by

2. Rosales, PA at Family Care Specialist Medical Group. Never
been hospitalized for these illnesses.
Psychiatric Illnesses Denies any psychiatric illness.
Surgical History Denies history of surgeries.
Trauma, Injuries or Accidents MVA in 2013 (rear ended) in Los
Angeles and was rx NSAID for neck/body pain.
Obstetric History (female only) G:3 (history of 1 induced
abortion), P:2 (both are males NSVD without complications
during pregnancy).
Transfusion History Denies history of transfusions.
Current Health Status
Medications Amitriptyline HCL 25mg PO QD at night. (Started:
April 2014, Classification: Analgesics, Mechanism of action:
Inhibits norepinephrine and serotonin reuptake, Adverse
reactions: Hypotension- orthostatic, htn, syncope, Side effects:
Drowsiness, dizziness, constipation, Special related tests: serum
drug levels, ecg, and in peds bp and hr. Taking medication as
directed without any assistance (Epocrates, 2015).
ProAir HFA 90 mcg PO 2 puffs q4h (inhalant) PRN. (Started: at
the age of 21 years old, Classification: Beta-2 agonists 1: short
acting inhalant, Mechanism of action: Selectively stimulates
beta-2 adrenergic receptors, relaxing airways smooth muscle,
Adverse reactions: Bronchospasm- paradoxical, anaphylaxis,
hypersensitivity, arrhythmia, Side effects: Cough, bad taste,
nausea, headache, throat irritation. Taking medication as
directed without any assistance (Epocrates, 2015).
Ibuprofen 800mg PO q8h PRN. (Started: 2010, Classification:
Analgesics/NSAID, Mechanism of action: Inhibits
cyclooxygenase, reducing prostaglandin and thromboxane
synthesis, Adverse reactions: GI bleeding, GI perforation/ulcer,
MI, strokes, Side effects: nausea, dizziness, constipation,
tinnitus, Special related tests: CBC, chemistry profile if long-
term tx; BP; s/sx hepatic impairment in peds. Taking medication
as directed without any assistance (Epocrates, 2015).
Allergies (drug reactions) Imitrex (sob) 2 years ago. Denies

3. allergies of food.
Health Screenings States “normal” for Pap 2012, cholesterol
2015, chest x-ray 2014, tb test 2013, SBE (monthly) April 2015.
Denies having an ekg, fobt, mammography, and rectal exam.
Habits Denies tobacco, alcohol, drug use.
Alternative Therapies Denies history of alternative therapies.
Psychosocial History
Marital Status/significant others Not married. Has male partner
of 7 years.
Living conditions Lives with mother, father, 2 children, brother,
and nephew.
Domestic Violence (IPV or Abuse) Denies ipv or abuse.
Employment/economic concerns Unemployed. No economic
concerns.
Education Medical assistant certificate 2007, high school
diploma 2004.
Sexual History Sexually active with male (fidelity). Denies
history of std’s, sexual difficulties, and sexual habits.
Significant life events Grandparents death in 2014 and 2015.
Denies financial hardship, alcoholism, relocation, and abuse.
Mental status Anxiety and depression since 2014. Denies mood
changes, stress, and memory changes.
Spiritual Assessment
Faith Affiliation Catholicism
Spiritual or faith practices Attends church.
Places of hope Church and home.
Things, practices or people that provide support and peace
Family members and priests from church.
Family History
See attached genogram
Family Illnesses (positives and negatives)

4. Review of systems
General Considers to be a healthy individual. Usual weight of
150 lbs, appetite is 3 meals and 2 snacks per day, recent weight
loss of 5 lbs during the past month. Denies weakness, fatigue,
and fever.
Skin Denies rashes, lumps, itching dryness, color changes, and
changes in hair or nails.
Eyes Last eye exam (optometry) 2015 and was told has
stigmatism and rx glasses (doesn’t know rx). Denies pain,
redness, excessive tearing, double vision, and transient loss or
impairment of vision.
Ears Last hearing exam (audiometer) 2014 and results were
“okay”. Denies use of hearing device, hearing changes,
sensation of spinning, earaches, infection, discharge, and
ringing.
Nose/sinuses Denies frequent colds, nasal stuffiness, hay fever,
and nose bleeds.
Mouth/throat Last dental exam 2012 and results were 2 root
canals and 1 crown. Condition of teeth and gums “good”.
Denies bleeding gums, sore tongue, frequent sore throats,
hoarseness, bad breath, change in voice, and loss of or peculiar
taste.
Head/neck History of migraines and headaches. Denies double
visions lumps in neck, swollen glands, and pain or stiffness in
neck.
Breasts Pap 2012 and results “normal”. SBE done monthly and
last was April 2015. Denies lumps, pain, and nipple discharge.
Respiratory History ofAsthma since 21 years old with several
wheezing episodes, Last TB test 2014 (negative), chest x-ray
2014 (“normal”). Denies cough, sputum, coughing blood,
bronchitis, emphysema, pneumonia, and pleurisy.
Cardiac History of sob with exertion related to asthma. Denies
chest pain, rapid or skipped heartbeats, swelling, history of MI,
or abnormal cholesterol levels.
Gastrointestinal Denies trouble swallowing, heartburn, nausea,
vomiting of blood, indigestion, changes in bowel habits, rectal

5. bleeding or black tarry stools, constipation, diarrhea, abdominal
pain, food intolerance, excessive belching, or passing of gas,
hemorrhoids, liver or gall bladder trouble, hepatitis, and
jaundice.
Urinary Denies increased frequency of urination, increased
volume of urine, urination during usual sleeping hours,
immediate need to urinate, problem in initiating urination,
involuntary loss of urine, blood in urine, and history of urinary
stones.
Genitor-reproductive Age of onset menses at 12 years old.
Monthly menstruations with 4-5 days of duration (last May 6,
2015). Denies bleeding between periods or after intercourse,
last menstrual period, excessive pain during menstrual flow, age
at cessation of menstrual period, menopausal symptoms, post
menopausal bleeding, and vaginal discharge or itching. Birth
control methods (condoms).
Musculoskeletal Denies joint pains or stiffness, arthritis, gout,
backache, and muscle pains or cramps.
Neurological History of depression related to grandparents
death in 2014 and 2015. Denies nervousness, tension, mood.
Endocrine Denies thyroid trouble, heat or cold intolerance,
excessive sweating, diabetes, excessive thirst, eating or
urination.
Hematologic Denies anemia, easy bruising or bleeding.
Pertinent Health Problems List
Migraines
Asthma
Depression
Anxiety
Medical Diagnoses
Migraines, chronic (ICD-10: G43)

6. Asthma, mild intermittent (ICD-10: J45.20)
Depression, severe (ICD-10: F33.3)
Anxiety, unspecified (ICD-10: F41.8)
References
Amitriptyline (2015). Epocrates. Retrieved from:
https://online.epocrates.com/noFrame/showPage?
method=analyze&MonographId=135&MultiBrandAlert=false
Ibuprofen (2015). Epocrates. Retrieved from:
https://online.epocrates.com/noFrame/showPage?
method=drugs&MonographId=233&ActiveSectionId=12
ProAir HFA (2015). Epocrates. Retrieved from:
https://online.epocrates.com/noFrame/showPage?
method=analyze&MonographId=4404&MultiBrandAlert=false