UNIVERSITY OF PANGASINAN

PHINMA EDUCATION NETWORK

COLLEGE OF NURSING

COMPLETE HEALTH HISTORY

INTERVIEWER: ____________________________________ DATE: ____________________

BIOGRAPHICAL DATA
CLIENT NAME: _______________________________________________________________
ADDRESS: ___________________________________________________________________
PHONE/ MOBILE NUMBER: ______________________________________________________
DATE OF BIRTH: ______________________________________________________________
BIRTHPLACE: _________________________________________________________________
OCCUPATION: ________________________________________________________________
USUAL SOURCE OF HEALTH CARE: _________________________________________________
EMERGENCY CONTACT: _________________________________________________________
PATIENT PROFILE
AGE: _______
GENDER: __________________
NATIONALITY: ___________________
MARITAL STATUS: _________________

CHIEF COMPLAINT (HISTORY OF PRESENT ILLNESS):

__________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

PAST HEALTH HISTORY

_____________________________________________________________________________
_____________________________________________________________________________

MEDICAL HISTORY
ALLERGIES:
___ DRUG: ____________________________
___FOOD: ____________________________
___ENVIRONMENTAL: __________________________
___BLOOD REACTION: __________________________
___OTHERS: __________________________________

CURRENT MEDICATIONS: (PRESCRIPTION & OTC)

DRUG & DOSE FREQUENCY LAST DOSE
_________________ ___________ ___________
_________________ ___________ ___________
_________________ ___________ ___________
_________________ ___________ ___________

PREVIOUS HOSPITALIZATION: (ILLNESS, ACCIDENTS, INJURIES, BLOOD TRANSFUSION)

HOSPITALIZATIONS: ________________________________________________________________
OPERATIONS: _____________________________________________________________________
DATE: _________________________________________
COMMUNICABLE DISEASES/ CHRONIC/ SERIOUS ILLNESS: _____________________________________
CHILDHOOD ILLNESS: ________________________________________________________
IMMUNIZATIIONS/ DATE: _____________________________________________________
_________________________________________________________________________
_________________________________________________________________________
FAMILY HEALTH HISTORY

YES NO YES NO
ARTHRITIS HYPERTENSION
BLOOD PROBLEM (ANEMIA, KIDNEY PROBLEM
BLEEDING) LIVER PROBLEM
CANCER LUNG PROBLEM (ASTHMA,
DIABETES MELLITUS BRONCHITIS, PNEUMONIA, TB,
EYE PROBLEM (CATARACTS, SOB)
GLAUCOMA) STROKE
HEART DISEASE (MI, HEART THYROID PROBLEM
FAILURE) ULCER
GERD PSYCHOLOGICAL DISORDER
HIV/ AIDS

OBSTETRIC HISTORY (FEMALES)

LMP: ___________________________
GRAVIDA: _____ PARA: _____TERM: ______ PRETERM: _____ ABORTION: ______ LIVING: ______
MENOPAUSE: _____YES ____ NO
SOCIAL HISTORY
SMOKER _____NO _____YES (# OF PACKS/DAY _____ # OF YEARS ______) EVER TRIED TO QUIT? ____
ALCOHOL _____ NO _____ YES (TYPE _______________ AMOUNT/ LAST INTAKE: ______)
DRUGS _______ NO _____ YES (TYPE _______________ AMOUNT/ LAST INTAKE: ______)

RELIGIOUS & CULTURAL OBSERVATIONS _____________________________________________

ACTIVITIES OF DAILY LIVING

DIET & EXERCISE REGIMEN: ______________________________________________________
ELIMINATION PATTERNS: ________________________________________________________
SLEEP PATTERNS: ______________________________________________________________
WORK & LEISURE ACTIVITIES: _______________________________________________________
USE OF SAFETY MEASURES: (SEATBELT, HELMET, SUNSCREEN) _______________________________

HEALTH MAINTENANCE HISTORY:

YES NO DATE
COLONOSCOPY ____ ____ ________
DENTAL EXAMINATION ____ ____ ________
EYE EXAMINATION ____ ____ ________
IMMUNIZATIONS ____ ____ ________
MAMMOGRAPHY ____ ____ ________

FAMILY MEDICAL HISTORY

YES NO WHO (PARENT, GRANDPARENT,
ARTHRITIS ____ ____ SIBLING)
CANCER ____ ____ ___________________________
DIABETES MELLITUS ____ ____ ___________________________
 HEART DISEASE ____ ____ ___________________________
HYPERTENSION ____ ____ ___________________________
STROKE ___________________________

REVIEW SYSTEMS
VITAL SIGNS: BP: ____________ RR: _________ PR: __________ TEMP: ___________
WEIGHT: __________
SKIN: __________________________________________________________________________
_______________________________________________________________________________
HAIR: __________________________________________________________________________
NAILS: _________________________________________________________________________
EYES: __________________________________________________________________________
EARS: __________________________________________________________________________
NOSE & SINUSES: _________________________________________________________________
MOUTH: ________________________________________________________________________
THROAT & NECK: _________________________________________________________________
BREAST & AXILLA: ________________________________________________________________
RESPIRATORY: ___________________________________________________________________
CARDIOVASCULAR & PERIPHERAL VASCULAR SYSTEM: _____________________________________
_______________________________________________________________________________
GASTROINTESTINAL: _______________________________________________________________
URINARY: _______________________________________________________________________
_______________________________________________________________________________
MUSCULOSKELETAL: _______________________________________________________________
_______________________________________________________________________________
NEUROLOGICAL: __________________________________________________________________
_______________________________________________________________________________
PSYCHOLOGICAL: _________________________________________________________________
REPRODUCTIVE SYSTEM: ____________________________________________________________
NUTRITION: ______________________________________________________________________
ENDOCRINE: _____________________________________________________________________
LYMPH NODES: ___________________________________________________________________
HEMATOLOGICAL:
_________________________________________________________________