Shadow Health Comprehensive Assessment

Denies current acute health problems Reports diabetes Reports asthma

Reports last visit to a healthcare provider was 4 months ago Reports reason for last visit was annual gynecological exam Reports last general physical examination was 5 months ago

Reports taking diabetes medication Reports having an inhaler Reports taking prescription birth control pills

Reports diabetes medication is metformin Reports starting taking diabetes medication 5 months ago Reports that side effects of diabetes medication abated over time Reports taking diabetes medication twice daily Reports diabetes medication dose is 850 mg Denies adverse effects of diabetes medication

Reports asthma medication has not changed Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week Reports recommended dose is 1-3 puffs as needed Reports typically taking 2 puffs Reports sometimes needing 3 puffs to control symptoms Denies adverse effects of asthma medication

Reports starting birth control 4 months ago Reports reason for birth control was to manage PCOS symptoms Reports birth control is drospirenone and ethinyl estradiol (Yaz) Reports taking birth control pill daily Reports taking birth control pill at the same time every day Denies adverse side effects from birth control

Reports occasional ibuprofen use Denies OTC herbals Denies OTC supplements

Reports taking ibuprofen for cramps Reports ibuprofen is regular strength Reports ibuprofen is effective Reports last use of ibuprofen was six weeks ago

Reports allergies have not changed Reports penicillin allergy Reports cat allergy Reports dust allergy

Reports recently beginning dieting to manage diabetes Reports recently beginning exercising to manage diabetes

Reports checking blood sugar once a day Reports checking sugar in the morning Reports using glucometer Reports blood sugar number is usually around 90 Reports having adequate supplies

Denies change in asthma symptoms Reports belief that asthma is well-controlled Denies current asthma symptoms Reports last use of Proventil inhaler was yesterday

Reports optometrist visit Reports last optometrist visit was 3 months ago Reports recently prescribed eyeglasses Reports that glasses improve overall vision

Reports last menstrual period was 2 weeks ago Reports menstrual cycle is normal Reports rare cramping

Reports doing occasional breast exams Denies having a mammogram Denies changes to breasts Denies history of breast cancer

Reports recent weight loss Reports weight loss of about 10 pounds

Reports a typical breakfast is smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt Reports a typical lunch is dinner leftovers or tuna or chicken sandwich on wheat bread Reports a typical dinner is vegetables with a protein and brown rice or quinoa Reports a typical snack is carrot sticks or an apple

Denies drinking coffee Reports only caffeine is diet Coke Reports drinking 2 diet Cokes per day

Finding: Reports drinking 2-3 nights per month Reports having 2 or 3 drinks when out with friends

Denies tobacco use Denies vaping

Reports history of smoking recreational marijuana

Denies sexual activity

Denies mental health issues

Denies general HEENT issues

Denies current breathing problems Reports occasional shortness of breath Reports occasional wheezing Reports occasional chest tightness Denies pain while breathing Denies coughing

Denies cardiovascular issues

Denies gastrointestinal issues

Denies genitourinary issues

Denies musculoskeletal issues

Denies neurological issues

Denies integumentary issues