STUDENT NURSE(S):

College of Nursing
Foundation University
Dumaguete City

I. DEMOGRAPHIC DATA

Name of Patient: _______________________________________________ Room & Bed: _______ Date & Time of Admission:
___________________
Sex: ____ Age: ____ Religion: __________________ Marital Status: ______ Educational Attainment:
_____________________
Address: _____________________________________________________________________________ Nationality: ___________

Doctor(s) in Charge: ___________________________________________________________________

II. Chief Complaints/ Reason for Seeking Medical Care:

III. History of Present Illness:

IV. General Impression:

 FUNCTIONAL HEALTH PATTERN

USUAL HEALTH PATTERN INITIAL APPRAISAL ONGOING APPRAISAL

( ) ( )

A. HEALTH PERCEPTION- HEALTH

MANAGEMENT PATTERN
B. NUTRITIONAL- METABLOIC
PATTERN

C. ELIMINATION PATTERN

D. ACTIVITY- EXERCISE PATTERN

E. SLEEP- REST PATTERN

F. COGNITIVE-PERCEPTUAL PATTERN
G. SELF-PERCEPTION- SELF-CONCEPT
PATTERN

H. ROLE- RELATIONSHIP PATTERN

I. SEXUALITY- REPRODUCTIVE
PATTERN

J. COPING- STRESS TOLERANCE

PATTERN
K. VALUE- BELIEF PATTERN