SAINT AUGUSTINE SCHOOL OF NURSING

NURSING HISTORY AND PHYSICAL ASSESSMENT

I. PATIENTS PROFILE
Name
of
Patient:
______________________________________________________
Name of Hospital: _____________________ Ward: ________________ Bed
No: ___
Age:
___________
Sex:
____________
Weight:
___________
Height:_____________
Civil
Status:
_________________
Religion:
_________________________________
Address: _____________________________________________________________
Date
of
Admission:_________________
Attending
Physician:
___________________
Admitting
Diagnosis:
___________________________________________________
II. HISTORY OF PRESENT ILLNESS
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III.PAST MEDICAL HISTORY
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IV.VITAL SIGNS
Temperatur
e

Pulse Rate

Respiratory
Rate

Blood
Pressure

Remarks

General Survey
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Head and Neck
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Upper Extremities
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Thorax/Respiratory
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Cardiac
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Abdomen
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Lower Extremities
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Prepared by: JM Moscoso, RN, CMT