Clinical Duty – Ward Interview Form

Student: ________________________________________ Clinical Group/Year Level: ______________________

Date/Time of Interview: _____________________________ Interviewee: ________________________________

Hospital No.: ________________________________

I. PATIENT’S DEMOGRAPHIC PROFILE Ward/Room: ________________________________

Patient Name: __________________________________________________________ Age/Sex: _____________

Date of Birth: _________________ Place of Birth: ____________________________________________________
Permanent Address: ___________________________________________________________________________
Nationality: _________________ Religion: ________________ Educational Attainment: ____________________
Occupation: ___________________________________ Health Care Financing: ___________________________

Admission Date and Time: ____________________________ Re-admission: ______________________________

Source(s) of Medical Care: _______________________ Attending Physician: ______________________________

Chief Complaint: _____________________________________________________________________________

Admitting Diagnosis: _________________________________________________________________________
Final Diagnosis: _____________________________________________________________________________

Vital Signs upon Admission:

Temp.-_____°C PR-______ bpm RR-_____ cpm BP- _____/_____ mmHg
O2 Sat- _____ % Wt.-_____ kg. Ht.-_____ ft.

II. NURSING HEALTH HISTORY

A. HISTORY OF PRESENT ILLNESS (*Please indicate the s/s that the client experienced prior to hospitalization.)

B. PAST MEDICAL HISTORY

● Childhood illnesses and immunizations (include year): ( ) BCG ( ) Hep. B ( ) DPT ( ) OPV ( ) Measles
( ) COVID-19 ( ) Others: ______________________________________________________________
● Previous injuries: _____________________________________________________________________
● Chronic medical conditions: _____________________________________________________________
● Previous hospitalizations:
o Date of Admission: ______________ Length of hospital stay (if can still remember): _______________
o Reason for Admission: ______________________________________________________________
● Previous surgeries (include year): ________________________________________________________
● Allergies: __________________________________________________________________________
● Previous or Maintenance Medications: ___________________________________________________
__________________________________________________________________________________
● Date of last examination/Medical check-up: ________________
● Dietary preferences and/or restrictions: ___________________________________________________
● Obstetric history (for Female patients): *Refer to Gordon’s Typology, Pattern no. 9*
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

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 C. FAMILY HISTORY
(Indicate who among the patient’s relatives have the condition and encircle if from the paternal or maternal side)
● Cardiac Disorders (e.g. CHF, Stroke, Atherosclerosis, etc.) ( M / P ) – ______________________________________
● Hypertension ( M / P ) –__________________________________________________________________
● Diabetes Mellitus ( M / P ) –______________________________________________________________
● Hematologic Disorders (e.g. Anemia, ITP, DIC, Sickle-Cell Disease, etc.) ( M / P ) –_____________________________
● Kidney Disorders (e.g. CKD, Kidney stones, UTI, etc.) ( M / P ) –_________________________________________
● Hepatobiliary Disorders (e.g. Cirrhosis, Fatty Liver, Gallstones, etc.) ( M / P ) –________________________________
● Musculoskeletal Disorders (e.g. Arthritis, Osteoporosis, Injuries, etc.) ( M / P ) –_______________________________
● Communicable Diseases (e.g. Tuberculosis, Hepatitis, Measles, Mumps, Dengue, Diptheria, Cholera, Influenza, Varicella, etc.)
( M / P ) –_____________________________________________________________________________
● Cancer ( M / P ) –_______________________________________________________________________
● Previous Surgeries ( M / P ) –_____________________________________________________________
● Psychiatric Disorders (e.g. Depression, Bipolar, Schizophrenia, Anorexia, etc.) ( M / P ) –__________________________
● Genetic/Hereditary Conditions ( M / P ) –____________________________________________________
● COVID-19 ( M / P ) – ___________________________________________________________________
● Others: –____________________________________________________________________________
____________________________________________________________________________________
D. PSYCHOSOCIAL HISTORY(Questions asked/data may be gathered instead from Gordon’s Typology to avoid repetition)
(Include: Place of residence, residence structure materials, if with electricity, water source, what toilet type, how garbage is stored & disposed of,
means of cooking, nutrition & diet, meals & glasses of water consumed, elimination pattern, occupation, family structure & relationships, family income,
education, civil status, religions, usual ADLs, & exercise, alcohol & cigarette use, recreational substances use, sexual pattern, stage of development.)
Erik Erikson’s Developmental Stages
(0 – 1½) Infant – Trust vs. Mistrust
(1½ – 3) Toddler – Autonomy vs. Shame & Doubt
(3 – 2) Preschool – Initiative vs. Guilt
(5 – 12) School-Aged – Industry vs. Inferiority
(12-18) Adolescent – Identity vs. Role Confusion
(18-40) Young Adult – Intimacy vs. Isolation
(40-65) Middle Adult – Generativity vs. Stagnation
(65+) Old Adult – Ego Integrity vs. Despair

III. GORDON’S TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS

Health Pattern Guide Questions BEFORE NOW

(A year or months ago) (During admission)

1. Health Does the patient describe

Perception & himself as healthy? Why? What
Health score does he give himself?
Management
Pattern
When the patient feels sick,
what measures does he take?

2. Nutritional - How many meals does the

Metabolic patient eat in a day?
Pattern
How many glasses of water
consumed in a day?
How many snacks does the
patient eat in a day?

Who cooks the patient’s food?

What consists of breakfast?

What consists of lunch?

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 What consists of dinner?

What consists of snacks?

Drink any alcohol beverages?

How often?

Do you smoke? How often or

how many packs/sticks a day?

Use of any drugs or substances?

3. Elimination - How many times does the

Excretion patient void in a day?
Pattern
What is the quality of the urine?

How often does the patient

defecate?

What is the quality of the stool?

4. Activity - What does the patient do every

Exercise day?
Pattern

What is the patient’s form of

exercise?

5. Sleep - Rest How long does the patient

Pattern sleep?

What time does the patient

sleep and wake up?

What is the patient’s earliest

time to sleep and latest time to
wake up?

6. Cognitive - Is the patient oriented to time,

Perceptual place, and person?
Pattern Does the patient respond to
stimuli verbally and physically?

7. Self- How does the patient describe

Perception - and perceive himself?
Self-Concept
Pattern

8. Role - How many siblings do you

Relationship have? You are the ___ sibling?
Pattern
Is the patient supported by the
family?

How are the relationships

between each member of the
family?

What is the occupation of your

father? Your mother?

What school level are your

siblings/what is their
occupations?

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9. Sexuality - If Female: ***
Reproductive Menarche: _______________
Pattern
Average length of period:
Cycle/Pattern of menses:
No of pads consumed/day:
Characteristics of menses:
(color, odor, amount, etc.)
Menopause: _____________
***
History of STDs:

Is the patient sexually active?

Use of Family Planning
methods:

Difficulty/problems during
intercourse?

Stage in Sigmund Freud’s

Psychosexual Theory:

10. Coping & What usually causes stress?

Stress
Tolerance What are the coping
Pattern mechanisms/activities to
stress?

Did the patient have any

previous traumatic
experiences?

11. Value & What is the patient’s religion?

Belief
Pattern
What are the patient’s religious
practices?

IV. PHYSICAL EXAMINATION & REVIEW OF SYSTEMS

Category Findings

General Appearance

Head, Eyes, Ears, Nose, Throat

Neck

Chest & Lungs

Cardiovascular

Abdomen

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 Genitourinary

Rectal

Musculoskeletal

Lymph Nodes

Extremities/Skin

Neurological

Others

V. LABORATORY & DIGANOSTIC TESTS & RESULTS

Date of Result Test/Exam Result Reference Range Clinical Significance

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 VI. IV FLUIDS & MEDICATIONS
IV FLUID Order Date/Time Hooked Date/Time Due

Medication Dosage, Route, Frequency, Timing

VII. LATEST KARDEX DETAILS

Date Medication IVF Diet Diagnostics/Labs Special Endorsement

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 VIII. LATEST VISIT TO THE PATIENT
Date/Time: ___________________________________
Patient Name: _______________________________________________ Age/Sex: ________ Ward/Room: ______________
CC/Dx: ______________________________________________________________________________________________
IVF (Type, rate & level): _____________________________________ Needle Gauge & Site: __________________________
Intake: __________________ Output: ________________________ (Time: _________________)
Attached Contraptions & Descriptions:
• O2 Therapy – ___________________________________________________________________________________
• ET/Tracheostomy – ______________________________________________________________________________
• NGT – ________________________________________________________________________________________
• Foley Bag Catheter – ____________________________________________________________________________
• JP Drain – _____________________________________________________________________________________
• Traction - _____________________________________________________________________________________
• Cast - ________________________________________________________________________________________
• Others: _______________________________________________________________________________________
Vital Signs: (Time: __________)
Temp: ______°C PR: ______ bpm RR: ______ cpm BP: _____/_____ mmHg
O2 Sat: ______ % Wt.: ______ kg Ht.: ______ ft
CBG: _______ mg/dL Time: _______

Possible Nursing Diagnoses / Charting Foci:

1. ___________________________________________ 4. ___________________________________________
2. ___________________________________________ 5. ___________________________________________
3. ___________________________________________ 6. ___________________________________________

Other Notes:
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Additional Guides:

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