PATIENT’S INFORMATION

Name: SLEEP- REST

Age:
Address: 1. Sleeping hour
Working Status: 2. Feeling when waking (fresh, headache,
Diagnostic Illness: drowsy)
Date: 3. Difficulty in sleeping
4. Medication
HEALTH PERCEPTION/ HEALTH
MANAGEMENT
1. Opinion about health: SELF-PERCEPTION/ SELF CONCEPT
2. Medications: 1. Self Perception about yourself
3. Do you know about the medications: 2. satisfaction with self-body image
3. Do you like grooming?
NUTRITIONAL AND METABOLIC

1. Weight loss
ROLE- RELATIONSHIP
2. Usual diet
3. Fluid intake 1. role in the family
4. Drug and alcohol consumption?
5. Ability to swallow? 2. All members are cooperative with you?
6. Skin and mucous membrane integrity?
3. decision maker of the family?
7. Body temperature?

ELIMINATION
SEXUALITY- REPRODUCTIVE
1. Bowel elimination? How often?
1. Sexual Problem
2. Urinary elimination? How often?
3. Color: Urine, feces, amount, frequency, 2. Active Sex (Direct sex)
odor
3. Laxative? 3. Passive Sex (without a partner) how often?
4. Problem during passing defecation
4. Digital Sex (sex toys) How often?
(pinagtakki/ pinagisbu)

ACTIVITY- EXERCISE
COPING/ STRESS TOLERANCE
1. Exercise/Hobbies?
1. Coping mechanism if stressed:
2. Breathing Problem?
3. changes in a heartbeat during exercise 2. Opinion about being stressed:
4. Do you feel pale?
5. Exercise problems? 3. Opinion about (Crying, anger, violence)

COGNITIVE- PERCEPTUAL
VALUE/ BELIEF
1. Orientation about time, place, and person
1. Religion
2. Difficulty in sentence making?
2. Your Religion Beliefs
3. Loss of memory
3. Opinion about belief during Illness: