Medical Centre Patient Health History

Medical Centre Patient Health History Form	Surname – GREEN
Given Name -Thomas
Address – “Belhaven”, Cliff Road, 2685
Date of Birth – 5/6/2005
Accompanied by: Stepfather – Mr Stone
Date: 18/9/2023
Next of kin’s name: Margaret Stone (mother)
Contact details: 0485 265 987
PATIENT/ CLIENT HISTORY
ALLERGIES:	REACTION
1	Food: eggs	Feels like vomiting
2	Drugs; Nil known	Nil
3	Other: nil	N/A
OCCUPATION:	School student
REASON FOR ADMISSION:	Central abdominal and shoulder pain, vomiting
Current or past health problems:	nil
FAMILIAL TENDENCIES/ CURRENT MEDICAL CONDITIONS: Circle response Yes/No
Diabetes Mellitus	Yes/No	Hypertension	Yes/No	Heart Disease	Yes/ No
Epilepsy	Yes/No	Asthma	Yes/No	Blood disorder	Yes/No
MEDICATIONS
Currently taking: nil
Cigarettes/day: nil	Alcohol/day: nil
Other non-prescription medications: nil
Nutrition
Last ate & drank	16/8/23
Usual bowel habits:	Normally once a day but not this morning
Usual urinary habits:	Normal
Social History
Who does the patient live with?	Mother, stepfather and sister
Will someone be able to care for the patient on discharge?	Yes