Biographical Data
Present Health History/Illness
Reason for seeking care
Sharp back pain when lifting weights, weakness, and premature fatigue.
Health patterns
The patient has health insurance. He is a supporter of traditional medicine and does not take any stimulating drugs and folk remedies.
Health goals
To get qualified treatment in order to return to work as soon as possible.
Health Beliefs and Practices
Beliefs and practices
The patient has never resorted to healers’ help. Despite religious beliefs, he is a supporter of modern methods of treatment and does not believe in non-traditional rituals.
Factors influencing healthcare decisions
Healthcare decisions are made in accordance with the presented symptoms.
Related traits, habits or acts
The man does not smoke but periodically drinks alcohol in small doses. His work involves lifting weights and other procedures that require the use of physical strength.
Medications
Prescription medications
The patient did not consult the doctor concerning his problem.
Over-the-counter medications
Sometimes the man takes Oxycontin to reduce pain. To get rid of nasal congestion that periodically occurs, the patient takes Mucinex.
Herbals
The patient does not believe in the power of herbal preparations and does not trust non-traditional drugs in the form of ointments on a natural basis. According to Akilen, Pimlott, Tsiami, and Robinson (2014), the denial of methods of traditional medicine is increasingly manifested in the modern society.
Past History
Childhood diseases
Pertussis, chickenpox, pneumonia. Complications did not arise.
Immunizations
Appropriate vaccinations were made in childhood.
Allergies
The patient is allergic to bee venom.
Blood transfusions
None.
Major illnesses
None.
Injuries
Dislocation of the shoulder joint after an unsuccessful injury.
Hospitalizations
None.
Labor and deliveries
Regular employment.
Surgeries
Adjustment of the shoulder joint.
Use of alcohol
The patient sometimes drinks alcohol.
Use of tobacco
The man does not smoke.
Use of illicit drugs
None.
Emotional History
Mental, emotional or psychiatric problems
The patient feels depressed because of the lack of opportunity to work hard enough, which is caused by back pain.
Family History
Father
Patient’s father is a pensioner; he worked as a heating network operator for almost the whole life.
Mother
Patient’s mother died four years ago in a car crash.
Siblings
None.
Grandparents
None.
Psychosocial/Occupational History
Occupational history
The man works on construction sites.
Educational level
The patient finished school in 2003. He attended construction courses and received a specialty of a worker.
Financial background
The family of the patient is middle-class. Housing conditions are acceptable.
Roles and Relationships
Significant others
None.
Support systems
The respondent has a few male friends who support him. His relationships with his wife are also trusting.
Ethnicity and Culture
Ethnicity and culture
The patient is of Asian origin, but he is not familiar enough with the peculiarities of the Eastern culture.
Physical and social characteristics that influence healthcare decisions
The features of physical work partly affect the patient’s condition, tiring him.
Spirituality
Religious and spiritual needs
The man’s family are parishioners of the local Baptist church.
Self-Concept
View of self-worth
The respondent is well aware of the importance of his work; he is sufficiently purposeful and motivated.
Future plans
The man plans to receive the post of senior worker and wants to have a baby.
Review of Systems
Skin, hair, nails
The skin of the man has a natural color. His nails have no visible deformation marks. Hair is dark and does not fall out.
Head, neck, related lymphatics
There are no traces of injuries or other defects on the head and neck of the patient. Lymph nodes are not enlarged.
Eyes
The shape of eyes is typically Asian.
Ears, nose, mouth, and throat
Oral cavity and throat have no signs of infection. There are symptoms of decay in two teeth. Patient’s nose and ears are healthy.
Respiratory
Breathing is not intermittent; there is no shortness of breath.
Breasts and axillae
The symptoms of inflammation and neoplasm are not found.
Cardiovascular
Heartbeat is normal; no chronic diseases are identified.
Peripheral vascular
Blood flow is normal.
Abdomen
The respondent does not suffer from excessive weight, and there is not a large fat layer in the abdominal cavity.
Urinary
There are no problems with urination.
Reproductive
The patient has no children, but he confirms that his reproductive function is normal.
Musculoskeletal
No visible deviations are found.
Neurologic
Problems with the loin in accordance with the patient’s complaints.
Reference
Akilen, R., Pimlott, Z., Tsiami, A., & Robinson, N. (2014). The use of complementary and alternative medicine by individuals with features of metabolic syndrome. Journal of Integrative Medicine, 12(3), 171-174.