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Shadow Health Comprehensive Assessment Tina Jones -Documentation (Electronic Health Record
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Shadow Health Comprehensive AssessmentTina Jones -Documentation (Electronic Health
Record
Asked about current health problems - ANSWER Denies current acute health
problems
Reports diabetes
Reports asthma
Asked about last visit to a healthcare provider - ANSWER 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
Asked about current prescription medications - ANSWER Reports taking diabetes
medication
Reports having an inhaler
Reports taking prescription birth control pills
Followed up about diabetes medication - ANSWER 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
Asked about asthma medication - ANSWER 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
Followed up about birth control prescription - ANSWER 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
Asked about current non-prescription medications - ANSWER Reports occasional
ibuprofen use
Denies OTC herbals
Denies OTC supplements
Followed up on ibuprofen (Advil) - ANSWER Reports taking ibuprofen for cramps
Reports ibuprofen is regular strength
Reports ibuprofen is effective
Reports last use of ibuprofen was six weeks ago
Asked about allergies - ANSWER Reports allergies have not changed
Reports penicillin allergy
Reports cat allergy
Reports dust allergy
Asked about diabetes management through lifestyle - ANSWER Reports recently
beginning dieting to manage diabetes
Reports recently beginning exercising to manage diabetes
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