Shadow,./Health,./Comprehensive,./Assessment,./Documentation,./(Tina,./Jone
s)
1. Vitals:,./•,./Height:,./170,./cm
• Weight:,./84,./kg
• BMI:,./29.0
• Blood,./Glucose:,./100
• RR:,./15,./•,./HR:,./78
• BP:128,.//,./82
• Pulse,./Ox:,./99%,./•,./Temperature:,./99.0,./F
2. Health,./History:, . / Ms.,./Jones,./is,./a,./28-year-
old,./African,./American,./single,./woman,./who,./presents,./for,./a,./pre-employ-
ment,./physical.,./She,./is,./the,./primary,./source,./of,./the,./history.,./Ms.,./Jones,./otters,./information,./freely,./and,./without,./contr
adiction.,./Speech,./is,./clear,./and,./coherent.,./She,./maintains,./eye,./contact,./throughout,./the,./interview.
3. General, . / Survey:, . / Ms.,./Jones,./is,./alert,./and,./oriented,,./seated,./upright,./on,./the,./examination,./table,,./and,./is,.
/in,./no
apparent,. / distress., . / She, ./ is, . / well-nourished,, . / well-developed,,./ and, ./ dressed,./ appropriately, ./ with,. / good,. / hygiene.
4. Reason,./for,./Visit:,./"I,./came,./in,./because,./I'm,./required,./to,./have,./a,./recent,./physical,./exam,./for,./the,./health,.
/insurance,./at,./my,./new,./job."
5. History,./of,./Present,./Illness:,./Ms.,./Jones,./reports,./that,./she,./recently,./obtained,./employment,./at,./Smith,,./Steven
s,,./Stewart,,./Silver,./&,./Company.,./She,./needs,./to,./obtain,./a,./pre-
employment,./physical,./prior,./to,./initiating,./employment.,./Today,./she,./denies,./any,./acute,./concerns.,./Her,./last,./healthc
are,./visit,./was,./4,./months,./ago,,./when,./she,./received,./her,./annual,./gynecological,./exam,./at,./Shadow,./Health,./Genera
l,./Clinic.,./Ms.,./Jones,./states,./that,./the,./gynecologist,./diagnosed,./her,./with,./polycystic,./ovarian,./syndrome,./and,./prescr
ibed,./oral,./contraceptives,./at,./that,./visit,,./which,./she,./is,./tolerating,./well.,./She,./has,./type,./2,./diabetes,,./which,./she,./is,./con
trolling,./with,./diet,,./exercise,,./and,./metformin,,./which,./she,./just,./started,./5,./months,./ago.,./She,./has,./no,./medication,./side,./
ettects,./at,./this,./time.,./She,./states,./that,./she,./feels,./healthy,,./is,./taking,./better,./care,./of,./herself,./than,./in,./the,./past,,./and,./is,./l
ooking, . / forward,./to,./beginning,./the,./new,./job.
6. Medications:,./•,./Metformin,,./850,./mg,./PO,./BID,./(last,./use:,./this,./morning)
• Drospirenone,./and,./ethinyl,./estradiol,./PO,./QD,./(last,./use:,./this,./morning)
• Albuterol,./90,./mcg/spray,./MDI,./1-3,./putts,./Q4H,./prn,./(last,./use:,./yesterday)
• Acetaminophen,./500-1000,./mg,./PO,./prn,./(headaches)
,./
,./
, Shadow,./Health,./Comprehensive,./Assessment,./Documentation,./(Tina,./Jone
s),./600,./mg,./PO,./TID,./prn,./(menstrual,./cramps:,./last,./taken,./6,./weeks,./ago)
• Ibuprofen
7. Allergies:, . / •,./Penicillin:,./rash
,./
,./
s)
1. Vitals:,./•,./Height:,./170,./cm
• Weight:,./84,./kg
• BMI:,./29.0
• Blood,./Glucose:,./100
• RR:,./15,./•,./HR:,./78
• BP:128,.//,./82
• Pulse,./Ox:,./99%,./•,./Temperature:,./99.0,./F
2. Health,./History:, . / Ms.,./Jones,./is,./a,./28-year-
old,./African,./American,./single,./woman,./who,./presents,./for,./a,./pre-employ-
ment,./physical.,./She,./is,./the,./primary,./source,./of,./the,./history.,./Ms.,./Jones,./otters,./information,./freely,./and,./without,./contr
adiction.,./Speech,./is,./clear,./and,./coherent.,./She,./maintains,./eye,./contact,./throughout,./the,./interview.
3. General, . / Survey:, . / Ms.,./Jones,./is,./alert,./and,./oriented,,./seated,./upright,./on,./the,./examination,./table,,./and,./is,.
/in,./no
apparent,. / distress., . / She, ./ is, . / well-nourished,, . / well-developed,,./ and, ./ dressed,./ appropriately, ./ with,. / good,. / hygiene.
4. Reason,./for,./Visit:,./"I,./came,./in,./because,./I'm,./required,./to,./have,./a,./recent,./physical,./exam,./for,./the,./health,.
/insurance,./at,./my,./new,./job."
5. History,./of,./Present,./Illness:,./Ms.,./Jones,./reports,./that,./she,./recently,./obtained,./employment,./at,./Smith,,./Steven
s,,./Stewart,,./Silver,./&,./Company.,./She,./needs,./to,./obtain,./a,./pre-
employment,./physical,./prior,./to,./initiating,./employment.,./Today,./she,./denies,./any,./acute,./concerns.,./Her,./last,./healthc
are,./visit,./was,./4,./months,./ago,,./when,./she,./received,./her,./annual,./gynecological,./exam,./at,./Shadow,./Health,./Genera
l,./Clinic.,./Ms.,./Jones,./states,./that,./the,./gynecologist,./diagnosed,./her,./with,./polycystic,./ovarian,./syndrome,./and,./prescr
ibed,./oral,./contraceptives,./at,./that,./visit,,./which,./she,./is,./tolerating,./well.,./She,./has,./type,./2,./diabetes,,./which,./she,./is,./con
trolling,./with,./diet,,./exercise,,./and,./metformin,,./which,./she,./just,./started,./5,./months,./ago.,./She,./has,./no,./medication,./side,./
ettects,./at,./this,./time.,./She,./states,./that,./she,./feels,./healthy,,./is,./taking,./better,./care,./of,./herself,./than,./in,./the,./past,,./and,./is,./l
ooking, . / forward,./to,./beginning,./the,./new,./job.
6. Medications:,./•,./Metformin,,./850,./mg,./PO,./BID,./(last,./use:,./this,./morning)
• Drospirenone,./and,./ethinyl,./estradiol,./PO,./QD,./(last,./use:,./this,./morning)
• Albuterol,./90,./mcg/spray,./MDI,./1-3,./putts,./Q4H,./prn,./(last,./use:,./yesterday)
• Acetaminophen,./500-1000,./mg,./PO,./prn,./(headaches)
,./
,./
, Shadow,./Health,./Comprehensive,./Assessment,./Documentation,./(Tina,./Jone
s),./600,./mg,./PO,./TID,./prn,./(menstrual,./cramps:,./last,./taken,./6,./weeks,./ago)
• Ibuprofen
7. Allergies:, . / •,./Penicillin:,./rash
,./
,./
