GENERAL HEALTH ASSESSMENT FORM

( HISTORY TAKING)

I- PERSONAL DATA

Name of Client/ Patient/ Repondent _____________________________________________

Home Address: _______________________________________________________________

Age: ______; Sex: _________; Civil Status: _____________ Religion:__________________

Occupation:______________________ ; Nationality:__________________________

In case of emergency, notify:______________________________________________

II- VITAL INFORMATION

A. Vital signs

T:______; P:________; RR:_______; BP:________

CR:_____; HT:_______; WT:_____________

B. Date Admitted: ____________________ Time:__________

C. Manner of Admission:______________________________

D. Chief Complaints: __________________________________________________________

___________________________________________________________________________

E. History of Present Illness: ____________________________________________________

III- APPEARANCE ON ADMISSION:

A. Physical

1. Body built: Slender:___________; Medium:______________; Obese______________

2. Appearance: Neat:____________; Untidy: _______________; Others: ____________

3. Skin Condition: Complexion: _________________________________

Color Texture: Smooth:______________ Rough:_________________

Presence of Lesions:_________________________________________

Others (specify): ____________________________________________

B. Level of Consciousness

Conscious: _____________________; Unconscious: ________________

Drowsy: _______________________; Comatose:__________________

Others (specify): ____________________________________________

C. Emotional Status:

Calm: _________________________; Disoriented:________________

Coherent:______________________; Incoherent:________________

Others (specify): ____________________________________________

IV. HISTORY TAKING:

A. Last Medical/ Surgical History:
__________________________________________________________________________

___________________________________________________________________________________________________________
_

B. Present Medical/ Surgical History:

_______________________________________________________________________

___________________________________________________________________________________________________________
_

C. Pertinent Family Medical/ Surgical History:

________________________________________________________________

___________________________________________________________________________________________________________
_

D. Social History:

1. Name of Spouse ( if married): _________________________________________

2. Number of Children: ________________________________________________

3. Highest Educational Attainment: ______________________________________

4. Source of Income: __________________________________________________

5. Vices/ Habits: ______________________________________________________

6. Hobbies/ Interests: _________________________________________________

7. House Owned: ____________; Rented:_____________; Shared: ____________

V- REACTIONS AND EXPECTATIONS:

A. Describe the Effects of Illness to Patient and Family:

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
_.

B. Describe the Feelings About Examination and Treatment:

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
_.

VI- NORMAL PATTERNS/ MODES OF FUNCTIONING:

A. Sleeping Patterns

Regular: _________________; Easily Awakened: __________________; Insomiac: ___________________

Sleeping Time: ________________________; Waking Up Time: __________________________________

B. Fluid Intake

Water: ________________; Beverages: ______________________; Others (specify): _________________

C. Elimination

Bowel Elimination: Daily: ____________________ Others ( specify ): ______________________________

 Urine Frequency: ___________________________; Color: ______________: Odor: ___________________

D. Personal Hygiene

Bath: Warm_____________ ; Cold: _______________ ; Tepid: ________________________

Oral: Mouthwash: _____________________ ; Frequency: ___________________________

E. Motor Function

R/ Handed: _________________ ;Paraplegic: __________________ ; Quadriplegic;

______________________

L/ Handed: __________________ ; Hemiplegic: ____________________________

Facial Paralysis: ______________________________________________________

Degree of Contractures: Head: _________________ Neck ____________________

Arm: _________________; Fingers: _______________ ; Legs: __________________ ; Knee: _________________

F. Sensory Function

Extent/ Degree of Loss of Sensation: ____________________________________________________

G. Reflexes

Babinski: _______________________ ; Kernigs: ________________________ Others: _____________________

VII- IDIOSYNCRASIES

A. Allergies

Food: ________________ ; Drugs: ______________________ ; Others: ________________________

 B. Preferences

Likes: Food: ______________________ ; Environment: _____________________________________

Others (specify) : _____________________________________________________________________

Dislikes: Food: ____________________________; Environment: ________________________________

Others (specify): ________________________________________________________________________

Interviewed by:____________________________________

Student

Date:________________________________________
___