Patient Centered Medicine 2
Revised: 2/7/10
DATA BASE: SAMPLE HISTORY
IDENTIFYING DATA 
CM is a 45-year-old, widowed, white saleswoman, born in the U.S.
CHIEF COMPLAINT
“Insomnia”
HISTORY OF PRESENT ILLNESS 
She is also concerned that they make her irritable with her family.  She isn't sleeping well, since she quit smoking cigs.
PAST MEDICAL HISTORY
Significant Childhood Illnesses
Only measles and chickenpox
Immunizations
Last tetanus 1998
Flu vaccine last November
Adult Illnesses/Hospitalizations
- Kidney infection 1982 treated with ampicillin and developed a generalized rash.
- Hypertension x 7 years, well controlled with home BPs normally 120-130/low 80s
Patient Centered Medicine 2
Psychiatric Illnesses/Hospitalizations
None
Operations
Tonsillectomy, age 6,
Appendectomy, age 13
Habits
tobacco : quit.
Injuries/Accidents
1998 foot laceration, 4 stitches
Obstetric History
G3, P3, 3 living children. Menarche age 12. Last menses 2 weeks ago.
Transfusions
None