Health History: Submitted By: Kyle Gwyn A. Mascariña

HEALTH
HISTORY
S U B M I T T E D B Y:
KYLE GWYN A. MASCARIÑA
BIOGRAPHICAL
D ATA
Name: Myra A. Mascariña
Address: Blk 3 Lot 12 Phase 3, Avocado Drive, Sta.
Isabelle Village, Avida Subdivision, Tayabas
City, Quezon Province
Phone: +639951356232
Gender: Female
Provider of History: Patient
Birth Date: October 20, 1982
Place of Birth: Taguig
Race or Ethnic Background: Asian, Filipino
Primary and Secondary Languages: Filipino, English
Marital Status: Single

Religion: Christian
Educational Level: College
Occupation: Call Center Agent
Significant Others or Support Kyle Gwyn A. Mascariña (Daughter)
Persons:
REASON FOR SEEKING
HEALTH CARE
“My chest often hurts especially when
I remember the death of my mother.
Using the staircase and even doing
little chores makes me tired easily.”
HISTORY OF PRESENT HEALTH CONCERN
“The chest pain is as if my heart is a pillow and held by someone too tight” as
CHARACTER
verbalized by the patient.
“The pain have started after my mother died due to cancer late 2019” as verbalized
ONSET
by the patient
“The pain is located on the left side of my chest where the heart is located.
LOCATION

Sometimes when the pain is too severe, the entire area aches” as verbalized by the
patient.
DURATION “Most of the time the pain lasts for 5 to 10 minutes, the worst pain lasted
approximately almost 25 minutes” as verbalized by the patient.
SEVERITY “On a scale of 1 to 10 where 1 is the lowest and 10 as the highest, I would say the
pain is 7. The pain is tolerable and bearable” as verbalized by the patient.
PATTERN “The pattern of the pain became worse as the time goes by especially whenever I
think of the death of my mother” as verbalized by the patient.
ASSOCIATED “I have goiter, that is why I palpitate a lot. I think it does contribute to the pain
FACTORS sometimes” as verbalized by the patient.
PAST HEALTH HISTORY
CHILDHOOD ILLNESSES: She has had some childhood illness like mumps and chicken pox when she
was little.
ACCIDENTS OR TRAUMATIC INJURIES: She had never gone through an accident or traumatic
injuries.
HOSPITALIZATIONS: She was hospitalized 4 times and those were when she gave birth to her 4
children. She is well immunized and yearly vaccinated by flu vaccine except for this year due to COVID.
SURGERIES: She had gone through cesarian surgeries and had done two wisdom tooth removal surgery
that was taken last year.
PSYCHIATRIC OR MENTAL ILLNESSES: She was never diagnosed with mental issues.
ALLERGIES: She does not have any allergy reaction towards food nor medication but her ear reacts to
nickel.
FAMILY HEALTH HISTORY
 Her Mom died at the age of 68 last December of 2019 due to lung
cancer while her Dad died last July of 2020 due to colon cancer.
 Her mother was healthy and has never been diagnosed with a disease
aside from having low blood pressure. Her father is diabetic and
constantly high blood.
 She cannot remember much of her grandparents as she was too little
when they were still alive and by the time, she was mentally
developed, they died already. She is not close much to her father
side.
 She has mentioned her aunts on her mother side are also diagnosed
with goiter.
 Her children were all well developed and none has any handicap
although her third child was born as premature.
REVIEW OF BODY SYSTEM FOR

CURRENT HEALTH PROBLEMS
SKIN, HAIR AND MOUTH, NOSE, HEART AND NECK ANUS, RECTUM AND
NAILS THROAT SINUSES VESSELS PROSTATE

THORAX AND PERIPHERAL MUSCULOSKELETAL
HEAD AND LUNGS VASCULAR SYSTEM SYSTEM
NECK

BREAST AND ABDOMEN NEUROLOGIC
EYES LYMPHATIC SYSTEM
SYSTEM
FEMALE GENITALIA

EARS
LIFESTYLE AND HEALTH
PRACTICES Description of a Activity on a
typical day typical day
Self-concept and self-care Education
responsibilities
Nutrition and weight Rest and sleep
management (habits and
Social Activities Type of work, level of patterns)
job satisfaction, work
stressors
Relationships 24-hour dietary intake Medication and
(fluid and foods) substance use
Residency, environment,
Values and Belief system neighborhood,
environmental risks
D E V E L O P M E N TA L
LEVEL
Y O U N G A D U LT:
INTIMACY VERSUS ISOLATION
M I D D L E S C E N T:
G E N E R AT I V I T Y V E R SU S STA G N AT I O N
O L D E R A D U LT:
E G O I N T E G R I T Y V E R S U S D E S PA I R

Health History: Submitted By: Kyle Gwyn A. Mascariña

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HEALTH

Primary and Secondary Languages: Filipino, English

Marital Status: Single

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