OLDER ADULT HEALTH HISTORY

1. Client Profile / Biographic Data

Name: Pastor M. Egam
Address: Sto. Nino District Pagadian City
Telephone: 925 1221
Date & place of birth / age: Rebokon, Dumalinao Zamboanga del Sur/ 84 years old
Sex: Male Race: Filipino Religion: Roman Catholic Marital Status: Married
Education: High School Undergrad
Nearest contact Person: Elsa E. Calma
Telephone: 09199334527
Advance directives: No advance directives
Living will: No living will
Code status: N/A
DPOA – Health care: N/A POA – Finance: N/A
2. Family Profile
Spouse (s): Arcadia Madlus Egam
Living: No living will
Health Status: Healthy
Age: 81
Occupation: Housewife
Deceased: No
Year of death: N/A
Cause of death: N/A
Children: 9
Living 8
Names and addresses: Emma Bongabong / Rebokon, Dumalinao Zambo sur
Edwardo Egam / Pagadian City

Elias Egam / Iligan City

Elizabeth Martinito / Rebokon, Dumalinao Zambo sur
Cristina Ema / Pagadian City
Elsa Calma / Pagadian City
Elgine Marcos / Pagadian City
Deceased: Evangeline Hontilla
Year of death: 2006
Cause of death Head Injury leading to comatose
Deceased: Anastasio Egam
Year of death 2003
Cause of death Diabetes

3. Occupational Profile
Current work status: No work
Previous occupations Farmer
Source (s) of income and adequacy for needs My daughter and son giving me a
monthly what we call pension its just a joke they just give me money especially
those who are professional and working abroad and I have a little farm just a little
Living Environment Profile
Type of dwelling Nuclear Family
Number of rooms 3 rooms Number of levels 2 levels
Number of people living in dwelling 2
Degree of privacy High Nearest neighbor My daughter Emma and Elizabeth
Address / Telephone: Rebokon, Dumalinao Zambo Sur
Recreational / Leisure Profile
Hobbies / Interests: Just listening to the radio program
Organizational memberships: Senior citizen
Vacations / Travel: Only in Iligan City
:

4. Resources / Support Systems Used

Religious preference / affiliation: I’m active member of Roman Catholic
Confidants: I don’t know about that thing
Who helps when need arises: My daughter Elgine Marcos and son Elias Egam
Physician (s) Dr. Salvador
Hospital: Provincial Hospital of Zamboanga del Sur
Clinic Only: Dr. Salvador’s clinic
Home health agency: None
Meals on Wheels: None
Adult day care: None
Other: None
Description of Typical Day (Include Usual Bedtime Ritual)
I’m just listening to the radio program then if I got boring I go to the sari2x store
of my daugther and istambay their, sometimes I wash my clothes when my
rheuma wont be bothering me.
5. Present Health Status
General health status during past year during past years
I only got to the hospital when I got a bad fall from horse back riding it was may
heathies day before that fall after that everything seems so bad I cant even carry
my self walking everytime I walk I waddle then I was diagnose having a
rheumatoid arthritis
Chief complaint Back pain and difficulty handling something like a pen because of
swan neck deformities.
Knowledge, understanding, and management of health problems (e.g., special
diet, dressing changes)
I have a special food like the fish I eat evryday and milk then a have a
maintenance drugs, I follow my physicians advice and food regulation I
understand even sometimes its hard to follow but I think its just for my owned
good.

Overall degree of function relative to health problems and medical diagnoses :

My doctors said I’m good for my ages but I also prepare myself for the worst
because I accept the fact that I older anytime soon God will be calling my name to
be on His side.

MEDICATIONS
Name (s): Indocin(Indomethacin)

Dosage: I forgot
How / when taken Every time my rheuma attack
Prescribing physician Dr. Salvador
Date of prescription I Forgot
Problems with adherence (complicated regimen with large number and variety
drugs, visual deficits, unpleasant side effects, perception of effectiveness,
difficulty obtaining, and affordability)

IMMUNIZATION STATUS (NOTE DATE OF MOST REXENT IMMUNIZATION)

Tetanus, diphtheria: None
PPD: None
Influenza: None
Pneumovax: None
ALLERGIES (NOTE SPECIFIC AGENT AND REACTION)
Drugs: None
Foods: None
Contact substances: None
Environmental factors: None

NUTRITION
24-hour diet recall (include fluid intake)
Special diet, food restrictions, or preferences: Fatty foods and salty foods and
sweets
History of weight gain / loss: Yes, when I’m younger just like you much lighter but
when I getting older and older my weigh getting up because maybe of slow
metabolic rate
Food consumption patterns (e.g., frequency, alone or with others): It’s just the
same
Problems affecting food intake (e.g., inadequate income, lack of transportation,
chewing / swallowing problems, and emotional stress) I don’t have any problem
with that one because I will eat anything they serve to except for the poisonous.
Habits: Listening to the radio program everyday then istambay to the little sari2x
store of my daugther
Past Health Status
Childhood illnesses: Only coughs and cold
Serious or chronic illnesses: I don’t have chronic illnesses
Trauma: I don’t have any trauma
Hospitalizations (note reason, date, place, duration, physician/s): A fall from
horseback riding it was late march of the year 2003 Dr. Pasensya
Operations (note type, date, place, reason, physician/s): No major operation yet
Obstetric history: N/A
Family History
Draw pedigree (identify grandparents, parents, aunts, uncles, siblings, spouse/s,
children): “abi nmo kani adto ala day sa una akong mga angkol ug ante bcg ako
mama ug papa ala gud kaayoy sakit nangamatay man lang to sila tungod sa ka
tigulang akong mama 98 gud to namatay ug ako papa 95 sa una nga utan raman
sige ang kinaon” as verbalized by the client.
Survey the following: cancer, diabetes mellitus, heart disease, hypertension,
seizure disorder, renal disease, arthritis, alcoholism, mental health problems,
anemia

6. Review of Systems
Check yes or no for each symptom and include full symptom analysis on positive
responses at end of each system.

GENERAL YES NO
Fatigue Yes
Weight change in past year No
Appetite change Yes
Fever No
Night sweats No
Sleeping difficulty No
Frequent colds, infections No
Self-rating of overall health status: 7 out of 10 where 10 is the highest
Ability to carry out activities of daily living (ADLs): I can wash my clothes and fill
the jar I the house but not as fast before. (Moderate)

INTEGUMENT YES NO
Lesions / wounds No
Pruritus No
Pigmentation changes Yes
Texture changes Yes
Nevi changes No
Frequent bruising No
Hair changes Yes
Nail changes Yes
Corns, bunions, calluses No
Chronic sun exposure No
Healing pattern of lesions, bruises: Poor

HEMATOPOIETIC YES NO
Abnormal bleeding / bruising No
Lymph node swelling No
Anemia N0
Blood transfusion history: None
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HEAD YES NO
Headache Yes
Past significant trauma No
Dizziness No
Scalp itching Yes

EYES YES NO
Vision changes Yes
Glasses/ contact lenses Yes
Pain No
Excessive tearing Yes
Pruritus No
Swelling around eyes No
Floaters No
Diplopia No
Blurring Yes
Photophobia No
Scotomata No
History of infections No
Date of most recent vision examination: September 2010
Date of most recent glaucoma check: September 2010
Impact on ADL performance: Sometimes it affects just like when im reading or
watching television

EARS YES NO
Hearing changes Yes
Discharge No
Tinnitus No
Vertigo No
Hearing sensitivity No
Prosthetic device(s) No
History of infection No
Date of most recent auditory examination: None
Usual ear care habits: Cotton buds
Impact on ADL performance: It has because I will pardon the words to clarify it but
it happen only sometimes I can’t hide the fact.

NOSE AND SINUSES YES NO

Rhinorrhea No
Discharge No
Epistaxis No
Obstruction No
Snoring Yes
Pain over sinuses No
Postnasal drip No
Allergies No
History of infections No
Self-rating of olfactory ability 9 is to 10

MOUTH AND THROAT YES NO

Sore throat No
Lesions/ ulcers No
Hoarseness No
Voice changes No
Difficulty swallowing No
Bleeding gums No
Caries No
Altered taste No
Difficulty chewing No
Prosthetic device(s) Yes
History of infections No
Date of most recent dental examination: None
Brushing pattern: Twice a day
Flossing pattern: 3 times a day
Denture cleaning routine and problems: Every night

NECK YES NO
Stiffness No
Pain / tenderness No
Lumps / masses No
Limited movement No

BREASTS YES NO
Lumps / masses No
Pain / tenderness No
Swelling No
Nipple discharge No
Nipple changes No
Breast self examination pattern N/A

Date and result of most recent mammogram N/A

RESPIRATORY YES NO
Cough Yes
Shortness of breath No
Hemoptysis No
Wheezing No
Asthma / respiratory allergy No
Date and results of most recent chest x-ray examination: December 2010

CARDIOVASCULAR YES NO
Chest pain / discomfort No
Palpitation No
Shortness of breath No
Dyspnea on exertion No
Paroxysmal nocturnal dyspnea No
Orthopnea Yes
Murmur No
Edema Yes
Varicosities No
Claudication No
Paresthesias No
Leg color changes Yes

GASTROINTESTINAL YES NO
Dysphagia No
Indigestion No
Heartburn Yes
Nausea / vomiting No
Hematemesis No
Appetite changes Yes
Food intolerances No
Ulcers No
Pain No
Jaundice No
Lumps / masses No
Change in bowel habits Yes
Diarrhea No
Constipation No
Melena No
Hemorrhoids No
Rectal bleeding No
Usual bowel pattern every morning I wake up

URINARY YES NO
Dysuria No
Frequency No
Dribbling No
Hesitancy No
Urgency No
Hematuria No
Polyuria Yes
Oliguria No
Nocturia Yes
Incontinence Yes
Painful urination No
Stones No
Infections No

GENITOREPRODUCTIVE – MALE YES NO

Lesions No
Discharge No
Testicular pain No
Testicular mass(es) No
Prostate problems No
Venereal disease(s) No
Change in sex drive Yes
Impotence Yes
Concerns re: sexual activity Yes
GENITOREPRODUCTIVE – FEMALE YES NO
Lesions
Discharge
Dyspareunia
Postcoitical bleeding
Pelvic pain
Cystocele / rectocele / prolapse
Venereal disease(s)
Infections
Concerns re: sexual activity
Menstrual history (age of onset, date of last menstrual period)
________________________________
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Menopausal history (age, symptoms, postmenopausal problems)
______________________________
___________________________________________________________________________________
Date and result of most recent Pap test
___________________________________________________
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GR __________________________ P _________________________ A
_________________________

MUSCULOSKELETAL YES NO
Joint pain Yes
Stiffness Yes
Joint swelling Yes
Deformity Yes
Spasm Yes
Cramping Yes
Muscle weakness Yes
Gait problems Yes
Back pain Yes
Prosthesis(es) Yes
Usual exercise pattern: Every morning I woke up I will do hiking just around my
house
Impact on ADL performance: Yes, it has it makes me so slow.

CENTRAL NERVOUS SYSTEM YES NO

Headache No
Seizures No
Syncope / drop attacks No
Paralysis No
Paresis No
Coordination problems No
Tic / tremor / spasm No
Paresthesias No
Head injury No
Memory problems No

ENDOCRINE SYSTEM YES NO

Head intolerance No
Cold intolerance No
Goiter No
Skin pigmentation / texture changes Yes
Hair changes Yes
Polyphagia No
Polydipsia No
Polyuria No

PSYCHOSOCIAL YES NO
Anxious No
Depressed No
Insomnia No
Crying spells No
Nervous No
Fearful No
Trouble with decision making No
Difficulty concentrating No
Statement of general feelings of satisfaction / frustration
I’m just satisfy with my life now even though I may have regret but I will accept
the fact that I can’t simply return to those mistakes and correct them but I’m very
will satisfy now.
Usual coping mechanisms: Rationalization
Current stresses: My age
Concerns about death: no, I don’t have any of it I accept the reality that sooner or
later I will going to die.
Impact on ADL performance: It has no impact.