Cerezo, Cielo Marie

BSNI-E

Children's ages and illnesses or handicaps:
unrecalled

NURSING HEALTH HISTORY FORMAT

Lifestyle and Health Practices

Biographical Data

Age of Parents

Biographical data Name: Jamille Dela Cruz
Address: 4c Caguioa Rd. Baguio City
Gender:Female
Marital status: Single
Age: 19
Birthdate: February 26, 1995
Place of Birth: Urdaneta City
Ethnic Background Educational Level: 3rd yr.
College Occupation: Student
Provider of history: Patient

Mother: 41 years old

Reasons for Seeking Health Care

Father side, Grandfather: Cancer of the bone

History of Present Health Concern

Father: 41 years old
Parent Illnesses
Mother: Kidney stones, Hypertension
Father: None
Grandparents ‘ illnesses
Father side, Grandmother: COPD

Mother side, Grandmother: Hypertension
Father side, Grandfather: None

Reasons for Seeking Health Care History of
Present Health Concern The character of the
patient is having an amoebiasis and she
encountered pain everytime her illness triggers. It
started last year and it is getting worse when she
eat raw foods . The pain is located at the left
umbilical region of the patient and it is last for 2
days. The severity of pain of the patient is 8. "It is
better when i take medicine but it is getting worse
when i eat raw foods". The patient claim's that she
vomit and she can't continue her activities when
the pain strikes.

Aunts’ and uncles’ age and illnesses
Aunt who is 47 y/o, no illness. Aunt who is 45 y/o
no illness. Uncle who is 43 y/, no illness.
Children’s age and illness or handicaps:
Client has no children

Review of
Problems

Systems

for

Current

Health

Past Health History
Problems at birth: none
Childhood Illnesses: Asthma and Weak Lungs
Immunization to date: 1st Year College
Adult Illnesses: Acidity and Ulcer
Surgeries: none
Prolonged pain: Allergies:
Dust, Animal, Medicine like Antibiotics Current
Medication: None

Skin,Hair and Nails: The client's skin is light
brown in color, normal temperature, it is smooth,
no lesion or rashes seen. The hair is black, it is
smooth and firm without hair loss and dundruff
and the nails are clean, pinkish in color and
smooth.
Head and Neck: No headache, no stiffness, no
difficulty of swallowinh and no enlarged lymph
nodes.

Family Health History
Ears: No signs of hearing loss and no pain.
Age of Parents (Living? Deceased date):
Mother: 46 Father: 47 Deceased: September 21,
2012 Parent Illnesses: Diabetics, Asthma and
Heart Problem Grandparent Illnesses: Heart
Problem
Aunts' and Uncles' age: Unrecalled

Eyes: The patient claim's that she is a nearsighted.
No redness seen and no black spots.
Mouth, Throat, Nose and Sinuses: The patient has
no mouth pain, no sore throat and no lesion. The
patient claim's that she is sneezing and coughing.

Thorax and Lungs: "Nahihirapan akong huminga
kapag masakit ang dibdib ko" "Sometimes i'm
experiencing shortness of breathing while i'm
doing some activities"
Breast and Regional Lymphatics: The patient
claims that she don't feel any pain over her breast
and there are no dimpling or lymph nodes in
axilla.
Heart and Neck Vessels: "I have a chest pain" The
patient massage her chest when she feels pain.
Peripheral Vascular: There are no pain noted.
Abdomen:"Minsan sumasakit yung tiyan ko at ang
ginagawa ko ay umiinom ako ng gatas para
mawala ang sakit"
Female Genitalia: No pain
Anus, Rectum and Prostate: The patient claim's
that she is constipated. She is drinking medicine
like diatabs and she drink greater 2L of water.
Musculoskeletal: No pain, no swelling, no redness
and no stiff joints Neurological: "Laging
sumasakit ang ulo kaya naman lagi kong
tinutulog" "Minsan paiba-iba ang mood ko"