COLLEGE OF NURSING

SILLIMAN UNIVERSITY
Dumaguete City

NURSING HISTORY
Part I. Demographic Information

Name: Age: Civil Status: Sex:

Address: Birth date: Educational Attainment:
Religion: Occupation: Nationality:
Room and Bed No.: Date and Time Admitted: Doctor(s) in charge:

Mother: Age: Occupation: Educational Attainment:

Father: Age: Occupation: Educational Attainement:
Insurance:

Admitting Impression:

Chief Complaints:

History of present illness:

General Impression of client (appearance upon first contact):

Past History:

Part II. Functional Health Patterns

 INITIAL APPRAISAL ONGOING APPRAISAL
USUAL FUNCTIONAL PATTERN
(Jan 12, 2006) (Jan 13,2006)

INITIAL APPRAISAL ONGOING APPRAISAL

USUAL FUNCTIONAL PATTERN
(Jan 12,2006) (Jan 13, 2006)