NAME:

SECTION:
TOOL NO.2 Data Collection of Individual Client Based on Eclectic Assessment Model

Area of Data Collection Interactions Observation/Measurement Norms and Standards

(Indicate page and paragraph number )
Health Perception and
Health Management
Pattern

Nutritional and Metabolic

Pattern

Elimination Pattern

Activity - Exercise
Pattern

Sleep - Rest Pattern

Cognitive-Perceptual
Pattern

Self-Perception and Self-

Concept Pattern
Role-Relationship Pattern

Sexuality-Reproductive
Pattern

Coping-Stress Tolerance
Pattern

Value-Belief Pattern

Others…….
( Any other things that we
haven’t talked about that
you’d like to mention?
Questions, Clarifications or
other concerns? )

NAME:
SECTION:
TOOL NO.3 Problem Identification

Functional Patterns and Clustered Data Health Inference Health Problem and Etiology
Health Perception and Health Management
Pattern:

Nutritional and Metabolic Pattern:

Elimination Pattern:

Activity - Exercise Pattern:

Sleep - Rest Pattern:

Cognitive-Perceptual Pattern:

Self-Perception and Self-Concept Pattern:

Role-Relationship Pattern:

Sexuality-Reproductive Pattern:
 Value-Belief Pattern:

Others:
(Any other things that we haven’t talked about that
you’d like to mention? Questions, Clarifications or
other concerns?)

NAME:
SECTION:
TOOL NO.1 Health History

Biographic Data:
(Narrative format. Should at least contain the following: Name, Address, Age, Sex, Date of Birth, Place of Birth, Race /Ethnic group, Primary
language spoken, other languages / dialects, Civil status, Highest Educational attainment (include course), Occupation, Religion orientation
(practicing), Healthcare financing and usual source of medical care/Who pays for health care needs? Income)

Chief Complaint or Reason for Visit: (If applicable):

History of Present Illness:

(Gives full, clear chronologic account of how each of the symptoms developed, their attributes and their context

Past History:
(Includes childhood uillnesse, childhood immunizations, allergies, accidents and injuries, hospitalization, and medications)

Family History of Illness:

(genogram / family tree of illnesses)

Review of Systems:
(Assesses common symptoms in each major body system, and identifies problems that the client has not mentioned)