Health Assessment Lecture

Download as docx, pdf, or txt
Download as docx, pdf, or txt
You are on page 1of 4

PATIENT MEDICAL RECORD

PERSONAL INFORMATION
Name: Renee Dwi Permata L. Messakaraeng Age: 18

Address: Bado Dangwa, Tabuk City, Kalinga Birthdate: Ocotber 21, 2003

Gender: Female Phone number: 09272738550

Email: reneedwimessakaraeng@gmail.com Occupation: Student

Other contact information: 092663794287 (Father) Civil Status: Single

PAST MEDICAL HISTORY

Multiple schemas in the heart- experienced during infancy but overcame it as years went by

Urinary Tract Infection- main reason for hospitalizations when in school age

Dengue- not hospitalized and opted for home care

Chicken pox- lasted for at least a week during elementary school

Stitches- gained several stitches in the left upper arm due to accident to a coke bottle

PRESENT MEDICAL HISTORY

Irregular menstruation- sometimes skips a month and lasts for mostly 3 days

Allergic reaction to pineapples- experiences itches and redness in face

Experience pain in abdomen sometimes

BMI Computation:
Weight- 58 kgs Underweight= less than 18.6
Height- 165 cm= 1.65 m Normal Range= 18.6-24.9

square of height(1.65x1.65)= 2.72 m2 Overweight= greater than 24.9

58 kgs/ 2.72m2= 21.32(NORMAL RANGE)


24- HOUR FOOD RECALL
Patient’s Name: Renee Dwi Permata L. Messakaraeng
Date Taken: 05/05/22

FOOD/ FULL/
Time of day AMOUNT
BEVERAGE SATISFIED?

6:30 am Coffee Half a cup

Bread One slice yes

12: 00 pm Rice Half cup

Squid 3 pieces

Mangoes 5 slices yes

3:30 pm Milktea 22 oz

6:00 pm Barbecue 2 sticks

Hotdog 1 stick yes

9:00 pm Rice Half a cup

Salmon 3 pieces

Mangoes 6 slices

Pineapple 3 slices yes

5-DAY SIMPLE HEALTHY MEAL PLAN


DAY 1 DAY 2 DAY 3 DAY 4 DAY 5

Breakfast - oatmeal - Egg - Hot - 1 cup - Orange


with fresh white Whole- fresh vanilla
or frozen omelet grain fruit oatmeal
(no sugar - Tea or cereal with - Tea or
added) hot blueberries coffee
fruit choco - Tea or
- tea or coffee
coffee
Mid-morning - Veggie - Big - 1 snack - 1 to 2 Cups - Carrots
snack salsa handful bag of of Veggie- and
Rich,
tortilla of grapes baby hummus
Bean-Rich
- 2 navel carrots Low-
oranges Sodium
or Soup, such
tangerines as…
Red Bean and
Leftover
Veggie Soup

Lunch - 2 Cups - Turkey - Vegetarian - Tuna - Tomato


Mixed sandwich chili Sandwich cream
Greens
soup
with 1 Cup
of Other
Veggies,
Chopped,
Dressed
with Aged
Balsamic
Vinegar
Mid-afternoon - 6 Ounces - Pear - Cottage - Sweet - 1-2 cups
snack of Nonfat - Popcorn cheese and potato of fresh
Plain or
fruit fruit
No-Sugar-
Added
Yogurt
with Your
Choice of
Berries
Swirled
Throughout
- 1 apple

Dinner - Salmon - Veggie - Spinach - Salad - Easy


with sweet Burger on salad with tangy
chili sauce a Whole-
honey salmon
Wheat Bun
with mustard
Roasted dressing
Red Bell
Peppers

Dessert(only if - Mixed - Fresh - Frozen - Berry - Fruit


hungry) berries Berries yogurt Mousse smoothie

You might also like