UNIVERSITY OF BOHOL

0186 Dr. Cecilio Putong Street

Tagbilaran City, Bohol, Philippines
Telefax No. (038)411-3101
www.universityofbohol.edu.ph
COLLEGE OF NURSING

Nursing Health Assessment

PATIENT PROFILE
Name: ______________________ Birth Date: ___________ Age: _______Gender: _______
Address:_______________________ Religion:_______________ Civil Status:____________
No. of children, if any: ________ Occupation/Profession: _____________________________
Highest Educational Attainment:_________________________________________________
Present Health Concern:______________________________________________________
Present Treatment:___________________________________________________________
PastTreatments:_____________________________________________________________
Past Hospitalizations (When & for what, include surgeries): ___________________________
__________________________________________________________________________
__________________________________________________________________________
Drug Allergies:________________________ Food Sensitivities:_______________________

SUBJECTIVE
Health Perception Health Management
Pattern
Reasons for seeking health care __________
____________________________________
____________________________________
____________________________________
Effects of illness on ADLs _______________
____________________________________
Use of alcohol ________________________
Use of tobacco _______________________
Last Immunizations ____________________
Compliance with treatments _____________
____________________________________
____________________________________
Daily Food and Fluid Intake
Usual Foods _________________________
Eating Times _________________________
OBJECTIVE
Appearance __________________________
____________________________________
Grooming ____________________________
____________________________________
Expressions __________________________
____________________________________
T ___________ PR ________ RR ________
BP __________ HT ________ WT ________
Skin
Color __________ Texture ___________
Temp __________ Lesions ___________
Turgor __________Moisture ___________
 SUBJECTIVE
Difficulty Chewing ___________________________
Dysphagia _________________________________
Sore Gums ________________________________
Sore Tongue _______________________________
Nausea and Vomiting ________________________
Abdominal Pains ____________________________
Antacids __________________________________
Elimination Pattern
Bowel Habits
Frequency ________ Color ________ Pain________
Consistency _____ Laxatives ______ Enemas _____
Suppositories ____ Infections ____ Colostomy _____
Bladder Habits
Frequency ________ Color ________ Pain________
Hematuria _____ Incontinence _____ Nocturia _____
Retention ______ Infections ______ Catheter ______
Daily Activities
Hygiene ___________________________________
Housework ________________________________
Leisure Activities ____________________________
Exercise Routine ____________________________
Sleep-Rest Pattern
Sleep Time ______________ Quality ____________
Difficulty falling asleep ________________________
Sleep aids _________ Sleep medications ________
OBJECTIVE
Oral Mucosa
Condition _____________________________
Lesions _____________________________
Teeth No. _____________________________
Gums _____________ Tongue ____________
Abdomen
Contour _______________________________
Lesions __________ Umbilicus ____________
Striae ____________ Vein ________________
Bowel sounds char. _____________________
Masses palpated _______________________
Musculoskeletal
Gait _______________ Posture ____________
Extremity swelling _______________________
Tenderness ____________________________
Symmetry _____________ ROM ___________
Respiratory
Thorax Shape __________________________
Symmetry _________ Retractions __________
Tenderness____________________________
Breath Sounds _________________________
Adventitious sounds _____________________

Sexuality/Reproduction Pattern Cardiovascular

Female Menstruation Heart sounds __________________________
Date began _____________ Last cycle ___________ Murmurs ______________________________
Problems __________________________________
Gravida ____ Para ___ Abortions ___ Infertility _____
Current pregnancy ___________________________
Contraception used __________________________
Undesirable side effects ______________________
Problems on genitalia ________________________
Problems on breasts _________________________

Sensory-Perceptual Pattern
Perceptions of:
Vision _____ Smell _____ Hearing _____
Taste _____ Sensation _____
Aids for vision _____________________________
Aids for hearing ____________________________

Role-Relationship Pattern
Role in Family ______________________________