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:
1. Client rapport should initially be established before you start your history taking. Don’t forget to observe
empathy and active listening throughout the assessment. Pose sensitive questions in a matter-of-fact tone
and adopt a non-judgmental demeanor.
2. The form is not designed to accommodate a large amount of detail about the client. You should briefly
document client information on the form, making sure that significant data are jotted down (i.e. important
dates, numbers/figures, lab/diagnostic test results, names of medications, and other data which are difficult to
remember). Use abbreviations as well as keywords which you can easily associate with the data provided to
you by your client. Use clear, straightforward language. AVOID redundancies and ‘flowery’ words, unless
verbalized by the patient.
3. When documenting client’s signs and symptoms (currently experienced or noted in the past), always describe
in detail these signs or symptoms, using the C.O.L.D.S.P.A. mnemonic as a guide:
 – haracter (Describe the sign or symptom. How does it feel, look, sound, smell & so forth?)
 – nset (When did it begin?)
 – ocation (Where is it? Does it radiate or move to another part of your body?)
 – uration (How long does it last? Does it recur?)
 – everity (How bad is it? For pain, rate it on a scale of 1 to 10, with 10 as the highest)
 – attern (What alleviates it or makes it better? What aggravates it or makes it worse?)
 – ssociated Signs/Symptoms (What other symptoms occur with it?)
4. The client’s health history should not be laden with your assumptions or own ideas. Since it is subjective data,
all data should reflect the patient’s or the informant’s account, without ‘sugar-coating’, ‘neutralizing’ or
‘masking’ the information provided to you.
5. Remember that your interpretation of the data provided to you may be different from what the client perceives
it to be. Thus, if you have difficulty in rephrasing or translating your client’s statements, especially if his/her
preferred dialect was used, place client verbalizations instead, enclosing them in quotation (“...”) marks.
6. Do not limit your assessment to the questions found on this form; explore further on information which you
deem significant or that need clarification.
7. Do not be tempted by the impulse of having to finish the form right away. Client may be too distressed to
answer all your questions in one sitting. You should plan several sessions throughout your shift to do the
history taking providing adequate rest periods between each session. You don’t necessarily have to follow the
sequence of this form. Ask the most relevant items first and the most sensitive ones last.
8. Use your creativity if having a hard time accomplishing the assessment or when having difficulty in engaging
the client for the history taking (i.e. attending to client’s needs while doing the assessment). Assessment doesn’t
have to appear too structured and tedious to the patient. Memorizing the items on the form will help you
achieve this. Although difficult for first-timers, with practice, the art and skill of history taking can be mastered.
:
1. The correct syntax of the chief complaint should be: In for complaints of [main s/s] noted [onset]
accompanied by [associated s/s].



2. Information you need to include for each chief complaint:

       
      

 
    
       
  

  

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:

     
  
   
     
   
 


 
    


    
   


   
   

     
     
 


       
 


 
     

  
  
 







:
 Write a chronological account (start each paragraph with ‘_______ PTA/PTC’) of the patient’s chief complaint/s & the
events surrounding it until time of admission. Note progression & any increase in severity.
 Accurately describe each sign/symptom using the C.O.L.D.S.P.A. mnemonic as your guide.
 Include consultations the patient had & any medications taken (indicate generic & brand name, dosage & timing) or
management done by the patient to manage the chief complaint before being admitted (also indicate if such
medication or management afforded relief – & if temporary or permanent relief)
 If diagnostic tests were taken, mention the date it was taken, who ordered it and if possible, the results of such test/s.
 If you believe that the chief complaint may be the direct extension of his ongoing chronic problem, then begin the HPI
with the chronic problem or with the past health history, making sure to include previous hospitalizations related to
condition, maintenance medications, treatments, dx tests, etc.
 Pay attention to detail as much as possible
 Include pertinent negatives (especially if an accompanying symptom is anticipated but was not present with the
client’s chief complaint)
 Conclude the HPI with an explanation of why the patient came to the hospital that day.

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:
- The Gordon's functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing
process to provide a more comprehensive nursing assessment of the patient.
- General guideline: Always COMPARE status of each functional health pattern BEFORE & DURING client’s illness or
hospitalization.

 “Has the amount you smoked changed? In what way?”

 “Do you think you have a smoking problem?”
 “What method(s) did you use to quit smoking? What was the outcome?”
 “What hinders you from quitting smoking?”
[score & interpretation: 7 to 10 pts = highly dependent; 4 to 6 pts = moderately
dependent; less than 4 pts = minimally dependent]

   

 

 

   
 

 

 “What type of alcoholic beverage do you usually prefer to drink? Beer? Wine? Gin? Rum? Vodka? Etc. ”

 “How often do you drink? How many bottles/glasses per day, week or month do you usually drink? How much do you
drink at one time? Do you drink to the point of intoxication?”

 “When was the last time you drank an alcoholic beverage? Give exact date & time, if possible.”

 “Has your drinking pattern changed? In what way?

 “When did you first start to drink?”
 “How long have you been drinking the amount that you are currently consuming?”
 “Have you ever lost consciousness or blacked out after drinking?”
 “Have you ever forgotten what happened when you were drinking?”
 “Do you drive after drinking?”
 “Did you ever drink during pregnancy? How much?” (for women)
 “Do you think you have a drinking problem?”
 “What hinders you from quitting drinking?”
[interpretation: An answer of ‘Yes’ to 2 or more questions indicates alcoholism & a thorough assessment of
alcohol consumption should be carried out]
 
 
 

 

 “What amount do you use (in grams or any employed unit of measurement)? How often do you use this drug?”

 “When did you first start to use drugs? Has the amount you taken changed? In what way?”
 For injected drugs: “Describe how you inject the drug. Do you share needles? Do you clean the needles between uses?
How?”
 “Have you ever overdosed? What happened?”
 “If on drug rehab, where did you enroll and what was its outcome? Further describe.”
 “Do you think you have a drug problem?
 “What hinders you from stopping drug use or from going through the said drug rehab program?”

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 Generic name & brand name column: “What prescription medications are you currently taking?”
 For dose: “What is the dose?”; for formulation: “How do you take this medication (e.g. pills, drops, inhaler, ointment,
etc.)?”; for frequency: “How often do you take this medication (e.g. once a day, before bedtime, etc.)?”
 Perceived purpose column: “Tell me the purpose of these medications.”
 For side effects, adverse reactions & other remarks column: “Have you ever experienced any side effects with this
medication? Any other problems you have noted associated with such medication? Is there a special way in which you
administer your medication (e.g. subcutaneous injection, through metered-dose inhaler)? If so, describe your
technique in which you administer your medication (e.g. for diabetic clients, describe technique for self-injecting
insulin - from preparation of the medication, to administering it, up to discarding of used materials).”

 Good compliance means that the patient religiously takes his/her current prescribed medications and maintenance
medications, on time and without fail.
 Fair compliance means that the patient sometimes misses a dose of his/her medications or sometimes don’t take
them on time.
 Poor compliance means that the patient habitually skips medication intake. It may also mean that the patient did not
complete the therapeutic regimen or only takes the supposed maintenance medication only when signs and
symptoms are experienced (e.g. taking a maintenance antihypertensive medication only when BP is elevated)

 Generic name & brand name column: “What over-the-counter medications, home remedies or other medications
NOT prescribed by a doctor, do you usually take?”
 For dose: “What is the dose?”; for formulation: “How do you take this medication (e.g. pills, drops, inhaler, ointment,
etc.)?”; for frequency: “How often do you take this medication (e.g. once a day, before bedtime, etc.)?”
 Common ailment/condition column: ““For what common ailment or condition do you usually take this medication
(e.g., fever, headache, dysmenorrhea, cough & colds, etc.)?”

 “What herbal medicines do you usually take? In what preparation do you take them (e.g. decoction, poultice, syrup)?
If medication is not commercially prepared, how do you prepare them (e.g. one cup of fresh leaves are coarsely
chopped then boiled for 3 minutes in an uncovered earthen pot in low flame; preparation is cooled and strained
before use)? How much of the herbal medication do you take (e.g. one part, ½ glass)? How do you take such herbal
medication (e.g. taken by mouth, applied to affected area)? How often do you take this medication (e.g. two times a
day, as needed)? How do you store the herbal medication and when do you dispose of it (e.g. kept lukewarm in a
thermos then disposed after one day)? What do you usually do if you don’t get better with the said herbal medicine?
 “What particular alternative treatment modalities do you receive? Tell me the purpose for receiving such modality.
How often do you receive such modality? Who administers such modality? Is the said modality effective for you? In
what way?”

 “What type of BP monitoring equipment do you use (e.g. aneroid, mercurial, digital arm, digital wrist)?”
 “Does the BP monitoring equipment come with a user manual or instructions handbook?”
 “Please describe the technique in which you or your significant other gets your blood pressure reading (from
preparing yourself before getting the BP reading up to how the BP reading is obtained)?”
 “What BP reading is considered normal and not normal for you? Do you keep a personal record of your regular BP
readings?”

 “Does your blood glucose monitor come with a user manual or instructions handbook?”
 “Please describe the technique in which you or your significant other obtain your blood glucose reading (from
preparing yourself before getting the reading, materials to prepare, calibration of blood glucose monitor and how
blood sample and the actual reading is obtained)?”
 “What blood glucose reading is considered normal and not normal for you? Do you keep a personal record of your
blood glucose readings?”
 “Where do you usually store the reagent strips? Do you reuse the lancets? If so, how often do you use the same lancet
before you replace them with a new one? Do you share lancets with another person? Where do you dispose of your
used lancets and reagent strips?”
 “How often do you replace the batteries of your blood glucose monitor?”

 Childhood immunizations refer to all vaccines received by the client when he/she was ≤ 12 years of age.
 If the client has a baby’s book, you may refer to this booklet for the timing & date of receipt of the said doses of the
vaccines which you can include in your assessment
 Meaning of vaccine abbreviations: BCG (Bacillus Calmette-Guèrin; this is a vaccine which helps give immunity against
TB), Hep. B (Hepatitis B), DPT (Diphtheria-Pertussis-Tetanus), OPV/IPV (Oral Polio Vaccine/Inactivated Polio
Vaccine), HiB (Haemophilus influenzae, type B), AMV (Attenuated Measles Vaccine), MMR (Measles, Mumps, Rubella),
RV (Rotavirus Vaccine), PPV/PnCV (Pneumococcal Polysaccharide Vaccine/Pneumococcal Conjugated Vaccine), Hep.
A (Hepatitis A)
 For doses & remarks, specify (1) how many doses of the said vaccine has the client received, (2) specific dates that
the client has received such doses, (3) any adverse reactions/side effects experienced after being given the said
vaccine

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 Adult immunizations refer to all vaccines received by the client when he/she was over 12 years of age.
 If the client has an immunization record, you may refer to this document for the timing & date of receipt of the said
doses of the vaccines
 Meaning of vaccine abbreviation (also see childhood immunizations): HPV (Human Papilloma Virus)
 For description of vaccination column: Primary dose refers to the first set of doses of the said vaccine received by
the client to develop immunity against a particular disease; booster dose refers to the succeeding dose received by
the client who has already acquired immunity against a particular disease and the said dose is given to maintain such
immunity; yearly dose refers to an annual dose of a vaccine which should be given yearly to acquire short-term
immunity against a particular disease (i.e. influenza)
 For other (specify) column: you may mention other reasons why the client was given the said vaccine as well as
adverse reactions noted after being given such vaccine

 A work shift refers to the time period during which a person is at work.
 Employees on a fixed work shift have a fixed work schedule throughout the year; whereas, those on a rotating shift
have varied work schedules which usually change every 3 to 5 days, every week, every 2 weeks, etc..

 An occupational hazard is any practice, behavior or condition or combination of these that can cause injury or illness
to employees/workers.
 Mechanical hazards are those that lead to traumatic physical injuries; physical hazards are energy forms which
could lead to illness or bodily injury; chemical hazards are chemicals (in any form) that may cause illness/injury;
biological hazards are life forms which may cause illness/injury; ergonomic hazards refer to workplace conditions
that pose the risk of injury to the muscles, tendons & joints of the worker ; psychosocial hazards are those which may
cause emotional trauma and psychological/mental illness

 Detached– a separate house which does not share a common wall with another house
 Semi-detached – two separate houses, which share a common wall and have separate entrances
 Terrace/link – houses built in rows of three or more units of which each has a common wall or walls adjoining with
the next house; have separate entrances
 Townhouse – structure is similar to a two-storey terrace/link house that attaches vertically or horizontally to each
other in a block; the only difference is that each floor is occupied by different occupants and has its own separate
access to the outside.
 Flat/Apartment – a multi-storey building which consists of separate housing units
 Condominium – a multi-storey building which is considered as an exclusive and luxurious property which has special
facilities (i.e. swimming pool, gymnasium) which could be shared by its occupants.
 Room in house/dormitory – a boarding house could be placed in this category
 Improvised hut/makeshift house – inferior living quarters generally considered temporary and unfit for living

 Urban –a locality where large buildings, commercial structures, etc. mostly abound; generally densely populated
 Rural – a locality where most of the land area is for agricultural use; in some areas, a large portion of the area is
wilderness; major sources of livelihood of people in the locality are farming, fishing, and the like

 Light –refers to such materials as bamboo, nipa, coconut leaves, cardboard, etc.
 Strong – a predominantly concrete house
 Mixed – refers to a combination of light materials, wood and/or concrete

 FORMULA: [(1/2 number of children under 10 years) + (number of couples) + (all other people aged 10 years and
over)] ÷ number of bedrooms = crowding index
 A crowding index in excess of 1.0 indicates household crowding and thereby implies that client’s living
quarters/housing unit is not adequate for the number of people living in it and increases risk of communicable
disease spread.

 Flush type– a water-sealed, and water-reliant toilet system where waste is disposed by flushing water (either by pour
flush or tank flush) through pipes into a public sewerage system or into an individual disposal system like an
individual septic tank
 Antipolo type – a non-water-reliant toilet; the toilet house is elevated and the shallow pit is extended upwards to the
platform (toilet floor) by means of a chute or pipe made of clay, metal, aluminum or board.
 Overhung latrine – a non-water-reliant toilet; the toilet house is constructed over a body of water (stream, lake or
river) into which excreta are allowed to fall freely
 Pit privy – consists of a pit covered by a platform with a hole; the hole is covered (close) or not covered (open); the
platform, may, in its simplest form, consist of only two pieces of wood or bamboo; is generally considered a
composting toilet and thus temporary (when the pit is full, another one is dug to serve as a pit privy)

 Public/communal – toilet is shared by several households; usually located outside a housing unit; sometimes a fee is
required for use of said facility;
 Individual/private-owned – toilet is used only by the occupants in a housing unit
 For the remarks portion, describe the overall sanitary condition of the toilet facility (e.g. is it functional & clean?)
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 None – there is no drainage system; waste water from the kitchen, bathroom, etc. flows directly to the ground,
oftentimes forming a nearly permanent pool
 Open drainage – waste water flows through a system of pipes (could be improvised from bamboo) to an open pit or
canal
 Closed/blind drainage – waste water flows through a system of close pipes to an underground pit or covered canal.
 For the remarks portion, describe the overall sanitary condition of the drainage facility (e.g. is it clogged up?)

 Collected by garbage truck (self-explanatory)

 Open dumping – garbage piled in a dumping place (with or without pit) with no soil covering
 Burning – regularly piles garbage and later burned in open air
 Buried in pit – garbage is placed in a pit and covered when filled up; there is no intention to dig it up later for use as
fertilizer
 Composting – garbage is first segregated and those which are biodegradable are placed in a pit and covered when
filled up; the pit is dug later for use as fertilizer
 For the remarks portion, describe the sanitary condition of waste container and manner of waste disposal (e.g. do
flies, other insect vectors, and rodents abound?)

 Distilled/purified – generally bought from a water refilling station (usually in gallons) and placed unto a water
dispenser
 Electric water pump – own freshwater supply brought from an underground water source to a tank or directly unto
household pipeline through an electric pump
 Piped system – public water supply brought from an outside water source directly unto a pipeline which leads into a
household; generally paid per month to a provider (i.e. MCWD)
 Open/deep well – water source is from a shallow hole dug in the ground; water is usually fetched using buckets tied
to ropes
 Artesian well – water supply is brought from an underground water source through a manual water pump (or
“bomba”/”poso”); usually located inside client’s property or shared by several households in a community
 For the remarks portion, describe the sanitary condition of water supply (e.g. is water potable or safe for drinking?)

 “In which part of the house do you store your medications, matches, knives and other sharps? Do they have a special
container? For medications, do their containers have child safety caps?”
 “In which part of the house do you store household chemicals (e.g. cleaning supplies, gasoline/kerosene, etc.)? In
which containers do you place them? For flammable chemicals and matches, how far are they from a heat source (i.e.
gas stove, electrical outlet)?”

 Special adaptations refer to modifications made to the client’s housing unit to accommodate or consider members in
the household with special needs (e.g. young children, pregnant women, elderly, those with physical disability),
usually to protect them from injury or to facilitate access (i.e. a ramp installed for a family member on a wheel chair)
 “Child proofing” refers to general safety measures done in the home to keep children from unintentional injury; this
includes installing stair gates, placing covers on electrical outlets, placing soft guards on furniture, etc.
 Slip-proofing of stairs and flooring is usually done by placing slip-resistant tapes on flooring and installing stair
treads to increase friction and prevent accidental slipping.

 “How often do you perform general cleaning of the household? What cleaning activities (i.e. sweeping, dusting,
vacuuming, mopping) are done on a daily, weekly and monthly basis?

 Give approximate distance (in meters) of such places. If client is unable to approximate distance, estimate how many
minutes it would take for him/her to reach that particular place either by walking distance or by a usual mode of
transportation (for example: Main Road: about 5 minutes on foot; Nearest Grocery Store: 10 minutes by car; Drug
Store: 5 minutes by tricycle, ...)

 For ‘meal taken at’: Specify where the client had eaten such meal within the last 24H (e.g. home, school canteen, etc.)
 For components of meal: Give exact or approximate amount of each food item that the client has consumed or usually
consume; include any beverages taken as well as method of preparation
 Example: For breakfast – 1 slice toasted bread, 1 cup skimmed milk, ½ cup oatmeal, 1 medium apple, 1 glass water;
For lunch – 8 oz.-bowl of sautéed vegetables, 1 pc. fried chicken (leg part), 1 cup cooked white rice, 1 glass orange
juice, 1 glass water; For PM snacks – 1 cup black coffee, 2 pcs. soda crackers; For dinner - 1 slice (4-oz.) grilled pork
chop, 1 cup cooked brown rice, 8-oz. bowl fresh vegetable salad (raw lettuce, raw tomato, raw cucumber) with 1 tbsp.
Italian dressing, 1 glass mango shake, 1 glass water.

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 Condiments refer to seasonings and sauces that add flavor or improve the taste of food. You need to specify type &
amount taken (approximate in tsp or tbsp).
 Examples of condiments are: ketchup, chili sauce, soy sauce, fish sauce (or patis), “ginamos”, Knorr® liquid seasoning,
table salt, Worcestershire sauce, etc.

 Examples of dietary restrictions (usually imposed by a physician for medical reasons) include a low salt & low fat diet
(for hypertensive clients and those with heart disease), low purine diet (for those with kidney problems), high protein &
high calorie diet (for those with third degree burns), and so forth.

 An example of a religious belief is the no-pork diet and daytime fasting during Ramadan for Islamic patients.
 An example of a cultural belief is the yin and yang diet of the Chinese; that is, eating hot foods for a ‘cold’ illness and
cold foods for a ‘hot’ illness.

 This refers to specific practices of obtaining food to ensure that they are fresh and not spoiled such as checking for
purple stamp on meat when buying pork products, checking for expiration dates on food labels of grocery items, etc.

 This refers to specific practices of storing food at home (usually to maintain their freshness), such as placing raw meat,
poultry and fish in the freezer, wrapping greens with brown paper and placing them on the vegetable crisper of the
refrigerator, placing labels on containers of leftover food and indicating the day & time they were prepared, discarding
any leftover food & blenderized feeding kept in the refrigerator if they are not consumed within 24 hours, etc.

 This refers to practices of preparing food before they are cooked or served (usually to maintain their nutritional value
and prevent food contamination) such as cutting vegetables shortly before cooking, washing vegetables thoroughly with
running water especially those to be served as fresh salads, separate chopping board for meat/poultry/fish, etc.
 Major methods of cooking food are by: (a) Moist-heat cooking methods: boiling, poaching, steaming, stewing/braising,
pressure cooking, & microwave cooking; (b) Dry-heat cooking methods: roasting, sautéing, grilling, & baking; and (c) Fry-
cooking methods: deep-frying, pan-frying, & stir-frying/wok frying.

 “What particular supplements are you taking? State its generic and brand name as applicable [e.g. multivitamins +
minerals (Centrum), vitamin E (Kirkland), vitamin B complex (Vaneular)].”
 “In what preparation and how much of the supplement do you take (e.g. 500 mg/tab, 6 scoops of powder dissolved in a
glass of warm water)?”
 “How often do you take the said food supplement (e.g. once a day)?”
 “For what reason are you taking the said supplement? Is it prescribed by a doctor?”

 If client reads food labels (especially nutrition facts), let him/her describe what he/she usually checks on the label; this
may include amount of calories per serving, sodium content, saturated fat content, etc.

 If client has a dental/orthodontic appliance, let client state the reason of having such appliance as well as routine care of
such appliance.

 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem.

 The Bristol Stool Scale was designed to be a communication aid for healthcare professionals to describe stool
consistency and form.
 Illustrations of the Bristol Stool Scale could be accessed online at http://en.wikipedia.org/wiki/Bristol_Stool_Scale

 “Aside from taking medication, what do you usually do to manage constipation? Are there particular foods that you eat
(i.e. papaya)? Any other usual practices to manage constipation besides medication?”

 Laxatives are drugs taken orally (usually in the form of a tablet or syrup) to relieve constipation; their main action is to
stimulate evacuation of the bowels
 An enema is a solution introduced into the rectum to promote evacuation of the bowels
 A suppository is a solid medication for insertion usually into the rectum, where it melts and releases the active
substance/medication; depending on the medication, it may act to stimulate evacuation of the bowels.
 In the ‘describe further’ portion: specify the generic and brand name of the said laxative, enema or suppository usually
taken by the client [i.e. bisacodyl (Dulcolax)]; also indicate the dose (in milligrams per tablet/suppository or in
milligrams per mL of syrup) and frequency of taking said medication (e.g. as needed). Also ask the client if the laxative,
enema or suppository is usually taken as self-medication or has it been prescribed by a doctor, and for what purpose the
medication is taken for. Ask the client of any side effects or adverse reactions noted when taking such medication.
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 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem. Such signs or symptoms may include problems
like black and tarry stools, hemorrhoids, rectal bleeding and other unusualities reported by the client.

 An ostomy is a surgically created opening that diverts stool to the outside of the body through an opening on the
abdomen called a stoma.
 An ileostomy is a surgically created opening between the ileum (usually the terminal ileum) of the small intestine and
the abdominal wall. On the other hand, a colostomy is a surgically created opening between any segment of the colon
and the abdominal wall to allow fecal elimination.

 “What was the reason you were created an ostomy? What is the usual appearance of your stoma? What is the usual
character of the drainage that comes out of your stoma?”
 “Please describe the usual practices you do to care for your stoma at home. Please also describe the technique in which
you care for your stoma. How often do you empty your ostomy pouch? How often do you change the entire ostomy
appliance? What products do you apply during stoma care?”
 “Do you usually irrigate or introduce tap water into your stoma? If so, how often do you perform the said irrigation?
Please describe your technique in irrigating your stoma.”
 “Please describe to me ways on how you prevent offensive odor of your stoma drainage. How do you prevent too much
from coming out of your stoma? What measures do you do to prevent blockage of your stoma?”

 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem.

 A urinary catheter is a short, plastic or rubber tube inserted into a patient’s bladder (usually via his or her urethra) to
allow urine to drain freely among other purposes.
 In the ‘describe further’ portion: state the type of catheter being inserted to the patient (2-way, 3-way, suprapubic, etc.);
it is also important to ask your client on usual practices done to care for his/her catheter and measures done to prevent a
secondary urinary infection.

 An assistive device is any device that is designed, made, or adapted to assist a person perform a particular task, usually
to assist a person in ambulating.
 In the ‘describe further’ portion: ask the client the reason for use of said assistive device and let him/her describe
technique in using the device for ambulating, getting up and down a chair and for using the stairs.

 The Katz Index of Independence in Activities of Daily Living, commonly referred to as the Katz ADL, ranks adequacy of
performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding. Clients are scored
yes/no for independence in each of the six functions. A score of 6 indicates full function, 4 indicates moderate
impairment, and 2 or less indicates severe functional impairment.

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 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem.

 Specify the generic and brand name of the said medication [i.e. alprazolam (Zanor)]; also indicate the dose (in
milligrams per tablet) and frequency of taking said medication (e.g. once a day before bedtime). Also ask the client if the
medication has been prescribed by a doctor. Ask the client of any side effects or adverse reactions noted when taking
such medication.

 “Does smoking, taking alcohol or drinking coffee within 2 hours from bedtime disrupt your sleep? If so, in what way?
Please describe.”

 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem.

 “What do you know about your present illness? What do you think are the factors that lead to it? What are its usual signs
and symptoms? What do you think is usually done to manage it? What do you think you should do to properly manage
your condition?, and so forth (varies per condition).

 “Please specify the grade of your corrective lenses. Do you wear your glasses or contact lenses regularly? If not, on which
instances do you especially wear them?”
 If using contact lens: “What type of contact lenses do you where? How long do you wear them? How do you clean them?
Describe the technique in which you apply and remove your contact lenses. How often do you have your contact lenses
replaced?”
 “Where and to whom did you have your corrective lenses made? How often do you have your eyes checked to determine
any adjustments needed for your corrective lenses? When were your corrective lenses last changed?”

 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem.

 “What type of hearing aid do you use? Do you put on or use your hearing aid regularly? If not, on which instances do you
especially use it? How do you clean it? Describe the technique in which you clean your hearing aid. Do you remove the
batteries during cleaning and when the hearing aid is not in use?”

 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem.

 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem.

 Questions were taken from the Primary Care Evaluation of Mental Disorders Screening Questionnaire for Depressive
Symptoms developed by Arnau, Meagher, Norris and Bramson (2001).
 Scoring: Score one point for each positive or ‘yes’ answer. A ‘no’ answer on both questions # 1 and # 2 indicates no
depression.
 For patients with five or more points, the diagnosis is major depressive disorder (and thus needs referral). If less than
five positive responses on questions # 3 to # 9, consider other depressive disorders (needs further evaluation by a
clinician). Patients who answer positively to the suicide question (question #9) are at high risk and need urgent
attention.

 “Do you have a plan to kill yourself? How do you plan to kill yourself? How would you carry out this plan? Do you have
access to the means to carry out the plan? Where would you kill yourself? What day or time of day do you plan to kill
yourself?”

 Note that immediate and significant family members are those that the client considers them to be and may not be
related to them by blood or may not necessarily belong to the same household as the patient.

 Nuclear family – typical family structure composed of mother, father and children
 Extended family – family structure extended up to grandparents; a three generational family
 Single parent family – children in the family identify only to one sole parent (mother or father)
 Blended/step family - describes families with mixed parents; in this case, one or both parents remarried, bringing
children of the former family into the new family
 Foster/adoptive family – describes families with legally adopted children (children not related by blood to parents)

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 Standard formal roles are roles explicitly given to family members as needed to keep the family functioning.
 They include breadwinner, child-rearer, homemaker, cook, financial manager and any other role that the client identifies
with (could be in his/her own words)
 In the describe further portion, let client describe how exactly such roles are carried out as well as the responsibilities
or tasks that go with these roles; also ask client if there are any pressures associated with these roles.

 Informal roles are covert and are used to meet the emotional needs of the individual to maintain the family equilibrium.
These roles could be adaptive or detrimental to the well-being of the family, depending on the unconscious purpose of
their use.
 A harmonizer mediates the differences that exist between other members by jesting or smoothing over disagreements
 A blocker tends toward the negative regarding all ideas
 A dominator tries to assert authority or superiority by manipulating the family or certain members
 A martyr wants nothing for self but sacrifices everything for the sake of other family members
 A caretaker is a member who is called on to nurture and care for other members in need
 A coordinator organizes and plans family activities
 The go-between is the family “switchboard” (often the mother) who transmits and monitors communication throughout
the family
 There may also be other informal roles that the client identifies with (could be in his/her own words).
 In the describe further portion, let client describe how exactly such roles are carried out as well as the responsibilities
or tasks that go with these roles; also ask client if there are any pressures associated with these roles

 “To what extent is your family bothered by this problem or stressful situation?”
 “How much of an effect does this problem have on your family’s usual pattern of living”
 “How much has this problem affected your family’s ability to work together as a family unit?”
 “Has your family ever experienced a similar concern in the past? How successful was your family in dealing with this
situation/problem in the past? What working coping strategies did you develop? Were these measures useful? Did the
situation improve?”
 “How strongly do you feel this current situation/problem will affect your family’s future?”
 “To what extent are family members able to help themselves in this present problem? To what extent do you expect
others to help your family with this problem? ”

 You may select from the items below on the characteristics of a family which could be used by the client to describe
his/her family:
- Communicates & listens to one another
- Affirms & supports one another
- Teaches respect for others
- Develops a sense of trust in members
- Displays a sense of play and humor
- Exhibits a sense of shared responsibility
- Teaches a sense of right and wrong
- Has a strong sense of family in which rituals and
traditions abound
- Has a balance of interaction among members
- Has a shared religious core
- Respects the privacy of one another
- Values service to others
- Fosters family table time and conversation
- Shares leisure time
- Admits to and seeks helps with problems

 Vaginal intercourse refers to the insertion of the penis into the vagina
 The person engaging in insertive anal sex inserts his penis into a man or woman’s anus
 The person engaging in receptive anal sex is having his or her anus penetrated by a man’s penis
 The person engaging in insertive oral sex is inserting his or her mouth into a man’s penis or inserting his or her tongue
into a woman’s vagina
 Receptive oral sex is when a man has his penis inserted on by a man or woman’s mouth or when a woman has her
vagina inserted on by a man or woman’s tongue

 Withdrawal/coitus interruptus - is a method of birth control in which a man, during intercourse, withdraws his penis
from a woman's vagina prior to ejaculation. The man then directs his ejaculate (semen) away from his partner's vagina in
an effort to avoid insemination.
 Calendar/rhythm – having sex only during a woman’s estimated infertile days based on a record of the length of
previous menstrual cycles
 Lactational amenorrhea – a natural family planning method wherein the woman fully breastfeeds her child postnatally
and as a result, remains amenorrheic and infertile for some time.
 Basal body temperature – is identifying the fertile and infertile period of a woman’s cycle by daily taking and recording
the rise in body temperature during and after ovulation
 Billing’s/cervical mucus method – abstaining from sexual intercourse during fertile (or wet) days among women;
involves inspecting underwear regularly for presence of mucus
 Symptothermal method – combination of Billing’s/cervical mucus method and basal body temperature.
 Condom – a sheath of latex rubber made to fit a man’s erect penis or woman’s vaginal canal to prevent the passage of
sperm cells and sexually transmitted infectious organisms into the vagina
 Diaphragm/ cervical cap - a dome-shaped cup with a flexible rim. It is made of silicone. It is inserted into the vagina.
When it is in place, it covers the cervix. The diaphragm blocks the opening to the uterus.
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 Depo-Provera – a brand of DMPA (depot-medroxyprogesterone acetate); an injectable medication derived from

progesterone usually administered intramuscularly every 3 months for long-term birth control among women
 Intrauterine device (IUD) – an object placed in the uterus to prevent pregnancy by preventing sperm to join the egg
 Ligation – also known as bilateral tubal ligation; female sterilization which involves cutting or blocking the two fallopian
tubes for female sterilization; it is a permanent method of contraception
 Vasectomy – male sterilization wherein the vas deferens (passage of sperm) is tied and cut or blocked through a small
opening on the scrotal skin; it is a permanent method of contraception

 If married: “Who usually decides on the form of contraception or family planning method to be used? How are decisions
regarding this usually made with your partner?”
 For natural methods: “Describe how you exactly perform such method or technique. Has such technique usually been
effective for you?”
 For condoms: “Do you put on a condom during vaginal, oral and anal intercourse? Describe the technique in which you
put on a condom as well as removing it after intercourse. Do you put on lubricants on the condom? If so, what do you use
to lubricate the condom? Do you change condoms in between sexual acts? How about if you transfer to another sexual
route (i.e. from the mouth to the vagina)?”
 For diaphragm/cervical cap: “How do you use the diaphragm/cervical cap? How long do you leave the
diaphragm/cervical cap in? How do you take care of it (e.g. washing with soap and water; check for holes, weak spots,
cracks, or wrinkles)? When do you replace it?”
 For pills & Depo-Provera: “What is the generic name and brand name of medication taken of such medication? What is
its dose, timing and frequency of administration? Who prescribed this medication for you? How long have you been
taking such medication? Are there any side effects noted while on it?” For pills, “What do you usually do when you forget
to take a day’s dose of your pill? How about if you miss two, three or more days of your dose?”
 For IUD: “Who inserted your IUD? What do you do to check the placement of your IUD and how often do you do it? Do
you have regular visits with your gynecologist to have the IUD regularly checked or replaced? If so, how often? Any
problems noted since the placement of your IUD?”
 For ligation/vasectomy: “What factors led to your decision of getting a ligation/vasectomy? When did you have this
procedure? Who performed it? How do you feel after getting the procedure? How has it affected your sexual relationship
with your partner?”
 Describe any side effects or adverse effects experienced while using a certain method.
 If a certain method was stopped, describe the reason for stopping and the duration it was used.

 “Could you tell me the specific sexually-transmitted infection (STI) that your partner had or may have or perhaps the
signs and symptoms that led you to believe he/she may have an STI?”
 “Did you have unsafe or unprotected vaginal, oral or anal sex with your infected partner?” (note that protected sex could
only be assumed if either partners used condoms during intercourse since condoms are the only known protection against
sexually-transmitted infections)
 “Did you have unsafe sex more than once?”

 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem.

 Menarche refers to a woman’s first menstruation. Average age of menarche is 12. 4 years old but may range from 9 to 17
years old.

 The last menstrual period refers to the first bleeding day of the woman’s most recent menstruation.

 The length of menstrual cycles varies from woman to woman, but the average length is 28 days (from the beginning of
one menstrual flow to the beginning of the next).
 Simply put, Day 1 of bleeding is referred to as Day 1 of the menstrual cycle. The length of the cycle is measured from Day
1 of one cycle (bleed) to Day 1 of the next cycle (bleed). For example, suppose today is May 2 and today is your day 1 of
bleeding. If day 1 of your preceding menstrual period was April 2, then the length of the preceding menstrual cycle is 30
days.

 Duration of menses/menstrual flow refers to the usual number of bleeding days you have for every menstrual cycle
(you may indicate a range if it usually varies). The length of the average menstrual flow is 4 to 6 days, although women
may have periods as short as 2 days or as long as 7 days.

 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem. For normal symptoms usually experienced before
and after menses like bloating, moodiness, and breast tenderness, there is NO need to expound and further describe.

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 Menopause refers to the cessation of menses. It is a normal physiologic process that occurs in women between the ages
of 40 to 58 years, with a mean age of 50.
 Age of onset refers to the age when the client’s menses have ceased. For symptoms, the client may have experienced hot
flashes, night sweats, mood swings, decreased appetite and vaginal dryness which accompany menopause. For
characteristic of bleeding, due to fluctuating hormonal levels during the perimenopausal period, the client may also
experience menstrual irregularities and so, client may need to describe bleeding during period which may be heavier or
may become scant. The client should also specify the amount of bleeding and the no. of pads soaked per day during the
perimenopausal period.

 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem.
 For hormone replacement therapy (HRT), ask the client what type of medication he/she has received and its dosage.
Also ask if there are problems noted with the said therapy.

 Breast self-examination is an option for women starting in their 20s to screen for breast cancer.
 Clinical breast examination involves having the breasts regularly examined by a doctor to screen for breast cancer. It is
recommended every 3 years for women in their 20s and 30s and every year for women 40 and over.
 A mammogram is a radiographic examination of the breasts to screen for breast cancer. Yearly mammograms are
recommended starting at age 40 and continuing for as long as a woman is in good health.
 A pap smear or Papanicolau smear is recommended for cervical cancer screening. It involves scraping of a portion of a
woman’s cervix for microscopic analysis to detect any malignant cells. The said screening should begin at age 21 and
should be done every 3 years for women ages 21 to 65; however, the said screening may be done frequently for high-risk
women and may be continued beyond age 65 depending on previous Pap smear results.
 An endometrial biopsy is recommended yearly for certain women known to be at risk for endometrial cancer. The said
procedure involves scraping a portion of a woman’s endometrial lining for microscopic analysis to detect any malignant
cells.

 For BSE: “At what age did you start doing BSE? How often do you perform BSE? Describe the technique in which you
perform BSE.”
 For the other screening tests: “At what age did you first have the test? How often do you have such test? When did you
last have the test? What were the results of such test?”

 For outcome of pregnancy: If the client delivered a live baby, check living; if delivered the baby at < 20 weeks AOG
(before the age of viability) either spontaneously (miscarriage) or elective as a result of pregnancy complications (i.e.
ectopic pregnancy), check abortion; if delivered a baby but died during birth or in utero at ≥ 20 weeks months AOG,
check stillbirth; specify other outcomes of pregnancy
 For weeks AOG Indicate the age of gestation or gestational age of child in weeks or months (gestational age refers to
the approximate length of time that elapsed since 14 days prior to fertilization up to the time of present fetal
development of the child)
 For hours in labor: Indicate the number of hours from the onset of regular uterine contractions and cervical dilatation
up to the delivery of the fetus.
 For wt. at birth: Indicate the weight of the baby or abortus (in grams or kilograms).
 For birth attended by: Indicate who attended the delivery of the child. TBA stands for traditional birth attendant.
 For type of delivery: NSVD stands for normal spontaneous vaginal delivery while C-section indicates Cesarean section;
other types of delivery include forceps and vacuum-assisted delivery.
 For other remarks: describe and expound on any complications the client had during that particular pregnancy
(pregnancy-induced hypertension, gestational diabetes, placenta previa, depression); if client had a C-section, also
mention the indication for the said surgery; also mention if the particularly pregnancy was induced; for multiple
gestation, you may divide the row into two for twins, three for triplets, etc. (although you may need a separate page).
Add other significant data (i.e. neonatal complications) pertinent to each pregnancy.

 Refer to table of client’s obstetric history to obtain client’s obstetrical score.

 Gravida: indicate the number of times the client has been pregnant
 Term: indicate the client’s number of full-term deliveries (37 weeks AOG or more)
 Pre-term: indicate the client’s number of pre-term deliveries (20 to less than 37 completed weeks AOG)
 Abortion: indicate the number of abortions (elective or spontaneous) the client had
 Living: indicate the number of client’s children living

 The postpartum period refers to the period after delivery of the baby up to 6 weeks after birth. Clients who belong to
this period are referred to as postpartum clients.

 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem. Also include the trimester of pregnancy wherein
the client had such illness.

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 Indicate the generic and brand name of said medications, including dosage, formulation, and frequency of
administration. Also indicate in which trimester of pregnancy the client had taken such medications.

 Labor is said to be induced if medications (such as oxytocin) are administered to facilitate or hasten the labor process. It
is spontaneous if otherwise.

 This is the age wherein the client first noted signs of puberty or the age when he thought that he was already an
adolescent. Manifestations at age of onset would include deepening of the voice, appearance of body hair, and so forth.

 Testicular self-examination is a monthly examination (usually after a warm shower) of the testicles and its supporting
structures to screen for testicular cancer. It is recommended for males ages 14 and over.
 Digital rectal examination is an examination of the rectum wherein a doctor inserts a gloved, lubricated finger to feel
for palpable structures (including the prostate) and check them for abnormalities. It is a recommended screening for
males 50 and over with known risk factors for prostate cancer
 Prostate-specific antigen (PSA) testing is a blood test to determine levels of the substance, PSA, which is usually
elevated in patients with prostate cancer. It is a recommended screening for males 50 and over with known risk factors
for prostate cancer.

 For TSE: “At what age did you start doing TSE? How often do you perform TSE? Describe the technique in which you
perform BSE.”
 For the other screening tests: “At what age did you first have the test/exam? How often do you have such test/exam?
When did you last have the test/exam? What were the results of such test/exam?”

 Use the C.O.L.D.S.P.A. mnemonic as guide for describing each sign or symptom. Include measures the client has done (i.e.
medications taken, consultations made, etc.) to manage such problem.

 This refers to activities or techniques that the client usually does to relieve stress.
 Coping methods and stress management activities may include but not limited to trying to forget, just doing nothing,
trying to solve the problem, drinking alcohol, taking drugs, over eating, blaming someone else, etc.
 The client may also employ stress management techniques (12S) which include: spirituality (or praying), self-
awareness, scheduling (time management), siesta (sleeping or taking a nap), stretching (aerobic exercise or simple
body movements), sensation techniques (includes massage), sports, socials (socializing with people to forget about the
stress; may also include going to the mall with friends), sounds and songs (listening to music), speak to me (talking to
someone about the problem), stress debriefing (going to a professional counselor), and smile.
 These coping methods and stress management activities may or may not benefit the client; some may even be
detrimental for the patient and his/her physical and mental health.

 “What are some of the traditions, values, beliefs, customs, rituals and norms that are most important in your culture?
Which are the ones related to your health and health practices that you want us to know about?”
 “Do you practice any special activities that are part of your cultural traditions?”
 “Are there special ways of showing respect or disrespect in your culture?”
 “Are there any cultural or ethnic sanctions or restrictions (related to expression of emotions and feelings, privacy,
exposure of body parts, response to illness, certain types of surgery, or certain types of medical treatments) that you
want to or must observe?”
 “By whom do you prefer to have your health and medical care provided: a nurse, physician, or other health care
provider? Do you prefer they have the same cultural background (or be the same age) or gender as your own?”
 “Are there any cultural preferences or restrictions related to touching, social distance, making eye contact, or other
verbal or nonverbal behaviors when communicating?”
 “In what ways do your family members believe the nurse, physician and other health care practitioners can help the
family members achieve their goals and dreams for health and well-being of the family?”

“What is your faith or belief? Do you consider yourself spiritual or religious?”

“What things do you believe in that give meaning to your life?”

“Is it important in your life? What influence does it have on how you take care of yourself?”
“How have your beliefs influenced your behavior during this illness?”
“What role do your beliefs play in regaining your health?”

“Are you a part of a spiritual or religious community?”

“Is this of support to you?”
“Is there a person or group of people who you really love or who are really important to you?”

How would you like me, your [nurse], to address these issues in your health care?”

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