Patient's Initial Assessment Report: Example 2
Patient Initial Assessment Report Patient Information: Name: Maria Gonzalez Age: 38 Gender: Female Date of Birth: October 22, 1985 Contact Number: (555) 987-6543 Address: 456 Oak Avenue, Lincoln, NE 68508 Referral Source: Referring Physician: Dr. Robert Lee Reason for Referral: Evaluation of recurring headaches and dizziness Presenting Complaint: Chief Complaint: Severe headaches and episodes of dizziness occurring over the past month Description of Headaches: Throbbing pain primarily on the right side of the head, associated with nausea and sensitivity to light Medical History: Past Medical History: Migraine headaches (diagnosed 5 years ago) Asthma (diagnosed in childhood, well-controlled) Surgical History: No significant surgical history Allergies: Penicillin (rash) Medications: Ibuprofen 400 mg as needed for headaches Albuterol inhaler as needed for asthma Family History: Father: Age 65 - Hypertension, history of stroke Mother: Age 63 - Type 2 Diabetes Mellitus, osteoarthr
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