GENERAL DATA

A. Personal Data Name of Client: ________________________

Nickname: ____________________________

Address: ______________________________ _____________________________________

Phone number: ________________________

Blood Type: ______ Age: _________________

Birthdate: _____________________________

Place of Birth: __________________________

Sex: ________ Citizenship: _______________

Race/Ethnicity: ________________________

Marital Status: ________________________

Religion: _____________________________

Educational attainment: _________________

Occupation: ___________________________

Hours of work per week: _________________

Spouse name: _________________________

Occupation: ___________________________

Contact Person: ________________________

Phone Number: ________________________

Date of Admission: ______________________

Health Care Financing: ___________________

Usual Source of Medical Care: _____________ _____________________________________ Cont…

Personal Data Source of referral: _______________________

Medical Doctor: _________________________

Final Diagnosis/Admitting Diagnosis/CC: ______________________________________

______________________________________ ______________________________________
______________________________________ ______________________________________

B. Source of Information (indicate percentage)

( ) Client
( ) Relative, specify relationship
( ) Friend
 ( ) Medical Records
( ) Referral
( ) others, specify

C. Chief Complaint ______________________________________

______________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________ ______________________________________

History of Present Illness

A. Precipitating / Palliative Factors: Setting (where, was and what was the person doing when
the symptoms started?)
B. Description (describe the symptoms)
- Localized
- Radiating, specify where
- Generalized
- Superficial
- Deep
- Others, specify
- Quality: throbbing, radiating, sharp, knifelike, burning, squeezing, stabbing, others please
specify
C. Region/Radiation/Related Symptoms
- Head (location, specify)
- Chest
- Abdomen
- Extremities *Aggravating Factors (What makes it worse?)
*Relieving factors
*Associated symptoms (is the primary symptom associated with other symptoms?)

Cont…History of Present Illness

D. Severity/Quantity of Symptoms

- no pain 0-1

- mild pain 2-3

- moderate pain 4-5

- severe pain 6-7

- very severe pain 8-9

- worst possible pain 10

E. Timing

- Onset of signs and symptoms: sudden, gradual, others, specify

- Duration of signs and symptoms

- Frequency of signs and symptoms

History of Past Illness

A. Childhood/Significant Illness

(Specify the treatment)

- Rubella, Rubeola, Mumps, Chicken pox, TB, DM, Anemia, Hepatitis, Urinary Problem, Seizure,
Addiction/drug abuse, Psychiatric disorder, others

Cont..History of Past Illness

B. Reason for Hospitalization/Diagnosis + Length of hospitalization (Date and Year) + Hospital

C. Surgeries/Serious Injuries + Date and Year/Hospital

D. Immunization (indicate if complete, incomplete, ongoing)

- Tetanus toxoid

- Anti hepatitis

- Others, specify

E. Laboratory Examination (indicate the result with exact values)

- CBC, UTZ, VDRL, UA, C&S, Others

F. Current Medication (Include name, dose, frequency, prescribed/OTC)

G. Allergies (food, medications, contact, others specify)

Family History

GENOGRAM

Health Perception Health Management Pattern

1. History

a. How has general health been?

b. Any colds in past year? When appropriate: absences from work?

c. Most important things you do to keep healthy? Think these things make a difference to health?
(Include family folk remedies when appropriate.) Use of cigarettes, alcohol, drugs? Breast self
examination?

d. Accidents (home, work, driving)?

e. In past, been easy to find ways to follow suggestions from physicians or nurses?
f. When appropriate: what do you think caused this illness? Actions taken when symptoms perceived?
Results of action?

g. When appropriate: things important to you in your health care? How can we be most helpful?

2. Examination—general health appearance

Nutritional-Metabolic Pattern

1. History

a. Typical daily food intake? (Describe.) Supplements (vitamins, type of snacks)?

b. Typical daily fluid intake? (Describe.)

c. Weight loss or gain? (Amount) Height loss or gain? (Amount)

d. Appetite?

e. Food or eating: Discomfort? Swallowing? Diet restrictions?

f. Heal well or poorly?

g. Skin problems: Lesions? Dryness?

h. Dental problems?

2. Examination

a. Skin: Bony prominences? Lesions? Color changes? Moistness?

b. Oral mucous membranes: Color? Moistness? Lesions?

c. Teeth: General appearance and alignment? Dentures? Cavities? Missing teeth?

d. Actual weight, height.

e. Temperature.

f. Intravenous feeding–parenteral feeding (specify)?

Elimination Pattern

1.History

a. Bowel elimination pattern? (Describe) Frequency? Character? Discomfort? Problem in control?

Laxatives?

b. Urinary elimination pattern? (Describe.) Frequency? Problem in control?

c. Excessive perspiration? Odor problems?

d. Body cavity drainage, suction, and so on? (Specify.)

2. Examination—when indicated: examine excreta or drain- age color and consistency

Sleep-Rest Pattern

1. History

a. Generally rested and ready for daily activities after sleep?

b. Sleep onset problems? Aids? Dreams (nightmares)? Early awakening?

c. Rest-relaxation periods?

2. Examination

a. When appropriate: Observe sleep pattern

Activity-Exercise Pattern

1. History

a. Sufficient energy for desired or required activities?

b. Exercise pattern? Type? Regularity?

c. Spare-time (leisure) activities? Child: play activities?

d. Perceived ability (code for level) for:

- Feeding _________ - Bathing _____________

- Toileting ________ - Home maintenance ___

- Dressing ________ - Grooming ___________

- General mobility ____ - Cooking __________

- Shopping _________ - Bed mobility ________

Functional Level Codes: Level 0: full self-care

• Level I: requires use of equipment or device

• Level II: requires assistance or supervision from another person

• Level III: requires assistance or supervision from another person and equipment or device

• Level IV: is dependent and does not participate

2. Examination

a. Demonstrated ability (code listed above) for: (same as above from feeding to bed mobility)

Cont.. Activity-Exercise Pattern

b. Gait____________ Posture_____________

Absent body part?__________________ (Specify)_________________________

c. Range of motion (joints) ___________________Muscle __________Firmness_______________

d. Hand grip ___________________________ Can pick up a pencil? ________________

e. Pulse (rate) ____ (rhythm) __________ _

Breath sounds____________

f. Respirations (rate) __________________ (rhythm) ____________ Breath

sounds___________________

g. Blood pressure ______________________

h. General appearance (grooming, hygiene, and energy level)

Cognitive-Perceptual Pattern

1. History

a. Hearing difficulty? Hearing aid?

b. Vision? Wear glasses? Last checked? When last changed?

c. Any change in memory lately?

d. Important decision easy or difficult to make?

e. Easiest way for you to learn things? Any difficulty?

f. Any discomfort? Pain? When appropriate: How do you manage it?

2. Examination

a. Orientation.

b. Hears whisper?

c. Reads newsprint?

d. Grasps ideas and questions (abstract, concrete)?

e. Language spoken.

f. Vocabulary level. Attention span.

Self-Perception—Self-Concept Pattern

1. History

a. How describe self? Most of the time, feel good (not so good) about self?

b. Changes in body or things you can’t do? Problem to you?

c. Changes in way you feel about self or body (since ill- ness started)?

d. Things frequently make you angry? Annoyed? Fearful? Anxious?

e. Ever feel you lose hope?

2. Examination

a. Eye contact. Attention span (distraction)

b. Voice and speech pattern. Body posture

c. Nervous (5) or relaxed (1); rate from 1 to 5.

d. Assertive (5) or passive (1); rate from 1 to 5

Roles-Relationships Pattern

1. History

a. Live alone? Family? Family structure (diagram)?

b. Any family problems you have difficulty handling (nu- clear or extended)?

c. Family or others depend on you for things? How managing?

d. When appropriate: How family or others feel about ill- ness or hospitalization?

e. When appropriate: Problems with children? Difficulty handling?

f. Belong to social groups? Close friends? Feel lonely (frequency)?

g. Things generally go well at work? (School?)

h. When appropriate: Income sufficient for needs?

i. Feel part of (or isolated in) neighborhood where living?

2. Examination

a. Interaction with family member(s) or others (if present).

Sexuality-Reproductive Pattern

1. History

a. When appropriate to age and situations: Sexual relationships satisfying? Changes? Problems?

b. When appropriate: Use of contraceptives? Problems?

c. Female: When menstruation started? Last menstrual period? Menstrual problems? Para? Gravida?

2. Examination

a. None unless problem identified or pelvic examination is part of full physical assessment.

Coping-Stress Tolerance Pattern

1. History
a. Any big changes in your life in the last year or two? Crisis?

b. Who’s most helpful in talking things over? Available to you now?

c. Tense or relaxed most of the time? When tense, what helps?

Cont …Coping and Stress Tolerance

d. Use any medicines, drugs, alcohol?

e. When (if) have big problems (any problems) in your life, how do you handle them?

f. Most of the time is this (are these) way(s) successful?

Values-Beliefs Pattern

1. History

a. Generally get things you want from life? Important plans for the future?

b. Religion important in life? When appropriate: Does this help when difficulties arise?

c. When appropriate: Will being here interfere with any religious practices?

2. Examination: None.

3. Other concerns

a. Any other things we haven’t talked about that you would like to mention?

b. Any questions?