Republic of the Philippines

Laguna State Polytechnic University

Province of Laguna
Regular Campuses: Siniloan, Sta. Cruz, Los Banos, San Pablo City
Satellite: Nagcarlan Laguna
Forwarding Address: Santa Cruz main Campus, Santa Cruz, Laguna, Philippines

COLLEGE OF NURSING AND ALLIED HEALTH

HEALTH ASSESSMENT

PATIENT'S PROFILE

Name: Age: Date of Birth:

Address: Contact Number:

Birth Place: Sex: Race/Ethic Origin:

Marital Status: Religious Preferences:

Admitting Physician: Source of Referral:

Insurance Information:

HEALTH HISTORY

Date Obtained: Source of Data:

Interpreter:

Reason for seeking health care:

PRESENT ILLNESS
1. Date of onset

2. Symptoms (type, location, frequency,

duration

3. Precipitating and or associated factors

4. Relieving and alleviating factors (eg.

timing, setting)

5. Effect on body function

6. Effect on ADLs and life-style

7. Treatment measures utilized (type,

frequency)

8. Effectiveness of treatment measures

PRESENT HEALTH STATUS
1. Perceived state of health

2. Health problems

3. Physical handicaps (type, management)

4. Prescription medications (name, dose,

route, frequency, for how long, by whom
prescribed, reason for taking, side
effects)

5. OTC medications (name, dose, route,

frequency, reason of taking,
effectiveness)

6. Home remedies used (type, frequency,

reason for used, effectiveness)

7. Complimentary/alternative therapies
used

8. Allergies (food, drug, environment, type

of reaction and management)

9. immunization status (dates and types

measles/mumps/rubella, polio, ,tetanus
booster, influenza, diphtheria, hepatitis,
pneumococcal pneumonia)

PAST HEALTH HISTORY

1. Childhood illness (strep throat, scarlet
fever, rheumatic fever, polio, mumps,
rubella, chicken pox)
 2. Serious illness (e.g. diabetes,
hypertension, heart diseases, cancer,
treatment)

3. Accident/injuries (type, date, treatment,

sequelae)

4. Hospitalizations (date, cause, hospital,

physical treatment, length of stay)

5. Surgery (date, type. postoperative

course, name of hospital and surgeon)

6. Obstetric history (number of

pregnancies, viable deliveries, course of
completed pregnancies, type of labor
and deliveries, sex, weight and general
condition of the neonate, postpartum
course, number of spontaneous
abortions, number of therapeutic
abortions, age of pregnancy at the time
of each abortions)

7. Exposure to toxins and environmental

pollutions (type, amount of exposure,
untoward effects)

8. Blood transfusion (date, number, toward

effects)

FAMILY MEDICAL HISTORY

1. Age and health, age and cause of death of

parents, grandparents, siblings

2. Blood relative history of heart disease,

hypertension, cerebrovascular disease,
diabetes, anemia, cancer, arthritis,
alcoholism, obesity, tuberculosis, renal
disorder, mental illness (specific disease,
age of onset, management)
 3. Communicable disease in close family
members, including spouse and children
(type, date, onset, treatment)

4. Age and health history of spouse and

children

5. Record family history in genogram form

Name of student: Date:

Clinical Instructor: Score: