Women and Children Protection Unit

HISTORIAN INTERVIEW FORM

DERMOGRAPHIC DATA
Patient’s Name Jade, Bian Age 15 DOB Sex F

Address Brgy Cabug, Bacolod City

Civil Status Single Occupation Student Nationality Filipino
Relationship to the Mother
patient
□ Acute Evidentiary Examination (within 72 hours of incident) □ Non-acute Examination
HISTORIAN INTERVIEW FORM
2 months prior to consult, patient was stated to have been hit by her father on the face with a water bottle.
Few days later, on Dec. 23, 2024, patient was picked upped by her mother where they rode a ceres and had onset of loss
of consciousness with stiffening of extremities as claimed with associated chest tightness, no memory of episodes with
upward rolling of eyeballs after episode. Patient noted to have another episode a few days later, on December 31, 2024,
where patient fell on her back.

1 month PTA, last January 8, 2024, had consult with doctor and given Levetiracetam and had CT scan requested which
showed unremarkable results

On Jan. 10, 2024, patient had another episode where she had seizure while sitting on a chair. Seizure episodes were
described to be shaking with associated shouting.

3 hours PTA, patient had another episode still with associated symptoms and 2 episodes of vomiting which prompted
ER consult.

Patient is the 3rd child from a broken family (separated parents). Her mother works as an OFW, and her together with
her siblings stayed with their father. She is a grade 10, but was not able to go to school since Dec. 23, 2024 after the
incident. Uses Cellphone and gadgets for entertainment and does not smoke, does not drink alcoholic beverages. Denies
being sexually active. Patient has history of being physically abused by father
And had previous suicidal ideations
Patient seen and examined, Awake, comfortable, not in cardiopulmonary distress, anicteric sclerae, pink conjunctivae,
moist oral mucosa, no neck vein engorgement (-) cervical lymphadenopathies (-) alar flaring, symmetrical chest
expansion, (-) subcostal retractions, clea breath sounds, Adynamic precordium, regular rhythm, (-) murmur, soft, non-
tender abdomen ,Warm extremities, Capillary refill time <2s, Full pulses, (-) edema, no note of bruises however was
not able to fully check other part of extremities since patient was uncooperative that time
No Neurologic Deficits noted; Motor strength 5/5 in all extremities All reflexes 2+