University of Santo Tomas

College of Nursing

HEALTH HISTORY

I. Biographical Data:

Name:__________________________________________________________________
Address:________________________________________________________________
Age: Sex: Citizenship: Religion:
Birthdate: Civil Status: Educ. Attainment:
BirthPlace:
Race: _________________________________________________________________
Occupation:_____________________________________________________________
Health Insurance: Philhealth? ___Yes ___No
Health Maintenance Organization (HMO)? ___Yes ____No
If Yes, please indicate: _________________________
Information obtained from: (Please check appropriate box.)
□ Patient
□ Others: Name ________________________________
Relationship: __________________________
Reliability of Source:______________________________________
Date Information Obtained:_________________________________

II. History of Present Health Illness:

Chief Complaint: ___________________Diagnosis: ________________________________

_____________________________________________________________________________
_____________________

______________________________________________________________________________________
_____________________________________

III. Past Health History (from childhood to present)

Surgeries: (Type, Dates, Hospital)

Hospitalizations & Illnesses( Kind, Inclusive Dates, Hospital)

_____________________________________________________________________________
_____________________________________________________________________________

_____________________________________________________________________________

Allergies: Food?___Yes____No; If Yes, kind of food?___________Reactions?_______________

Allergies: Medicine?____Yes____No; If Yes, name of medicine?___________
Reactions?_____________
Allergies : Latex?___Yes____No. Reactions _________________________________________
Allergies: Environment?____Yes_____No; If Yes, what kind?_________Reactions?__________
Immunizations : Complete?___Yes____No
Flu vaccine: Received? ___Yes____No; If Yes,Date received__________
Pneumonia vaccine: Received? ___Yes____No; If Yes,Date received__________

Medication Reconciliation:
Medicines taken at Home Medicines taken in the Hospital (if applicable)

IV. Family Health History

V. Psychosocial History:
A. Past events related to health:
Place of birth:______________
Places lived:__________________________________________________________________
Significant childhood/adolescent experiences:
_____________________________________________________________________________
_____________________________________________________________________________
B. Education and Occupation:
Jobs held in the past:
_____________________________________________________________________________
_________________________________________________________________________
Current position or job:__________________________________________________________
Length of time at position:_________________________
Work satisfaction and career goals:
_____________________________________________________________________________
_____________________________________________________________________________
________________________________________________________________________
C. Lifestyle Patterns:
Exercise:Type___________Frequency_____________Time spent_____________________
Sleep : Time person retires________Hrs per night_________Comfort Measures___________
Awakens rested?____Yes____No
Recreation :Type of activity____________Time spent________________
Nutrition:
(24hr diet recall):
Breakfast :__________________________________________________
Lunch:_____________________________________________________
Supper:____________________________________________________
Snacks:____________________________________________________
Restrictions:______________________________________________________
Idiosyncrasies:____________________________________________________
Caffeine :_____coffee____tea____chocolate_____soda/cola
Amount_______Frequency__________
Tobacco use: ____Yes___No. If Yes, how long?_______How much?___packs /day___sticks/day
Kind?(cigarette,pipe, cigar, marijuana)_________________________
Desire to quit?_____________________
Alcohol Use: ____Yes____No. If Yes, how long?_____How much?_____per day______per week

Kind?__________________________

Illicit Drug use: ___Yes___No. If Yes, how long?_____How much?____per day______per week

Kind?__________________________Route of administration?________________

Sexually active:____Yes ___No. Any sexually transmitted disease? __Yes__No. If Yes, indicate
what kind________________________________________________________

E: Self Concept:
View of self in the present:___________________________________________________
View of self in future:_______________________________________________________
Body image (level of satisfaction, concerns):
_____________________________________________________________________________
_____________________________________________________________________________

F. Physical or Mental disability:

Presence of disability (physical / mental):_____________________________________________
Effects of disability on function / ADLs:_______________________________________________
Accomodations needed to support functioning:________________________________________

G.Risk for abuse:

Physical injury in the past:________________________________________________________
Afraid of partner, caregiver or family member:_________________________________________

H. Stress and Coping Mechanisms:

Major concerns or problems at present:______________________________________________
Daily “Hassles”:_________________________________________________________________
Past coping patterns and outcomes:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Present coping strategies and anticipated outcomes:
_____________________________________________________________________________
_____________________________________________________________________________
Individual ‘s expectations of family/friends and health care team in problem resolution:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

I. Environment:
Physical :Living arrangements
Type of Housing:___________________________
Presence of Hazards:_______________________
Spiritual :
Religious beliefs & practices pertaining to health & illness:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Interpersonal :
Ethnic background:
Language/s spoken:_____________________________________
Folk practices used to maintain health or to cure
illness:_____________________________________________________________
__________________________________________________________________
__________________________________________________________________
Family relationships:
 Family structure:_________________________________________________
Roles :_________________________________________________________
Communication patterns:__________________________________________
Support system:_________________________________________________
Friendships : (quality of relationships)
__________________________________________________________________
__________________________________________________________________

VI. Functional Assessment

• Please refer to other page

 University of Santo Tomas
College of Nursing Patient
Care Record

REVIEW OF SYSTEMS

PATIENT’S NAME: RM NO: DATE:

CHIEF COMPLAINT: DIAGNOSIS:

VITAL SIGNS GENITOURINARY

Temp = □ oral □ rectal □ axilla □ W ithin normal level □ W NL except for:
PR = RR = BP = □ burning □ urgency □ dysuria □ hesitancy
PSYCHOSOCIAL □ urinary incontinence
□ Calm □ anuric □ polyuria □ nocturia
□ Anxious □ catheter □ drainage tubes
□ Cooperates with care Urine:
□ OTHER □ color □ amount
□ cloudy □ sediment □ heme
NEURO Genitalia: □ discharge
□ W ithin normal level □ W NL except for: □ OTHER
□ Level of Consciousness GCS:
□ Orientation MUSCOLOSKELETAL
□ Memory Deficit □ W ithin normal level □ W NL except for:
□ Sensory Deficit Aids □ hearing □ vision □ limitation of movement (location)
□ Cranial nerve deficit □ balance □ gait □ ROM □ assistive device
□ Language deficit □ joint swelling □ muscle weakness
□ OTHER □ muscle tone □ flaccid □
Activity level:
CARDIOVASCULAR □ OOB
□ W ithin normal level □ W NL except for: □ partial assistance
□ Irregular heart rate □ murmur □ complete assistance
□ Edema (location) □ OTHER
□ Coolness (location)
□ Color (location) INTEGUMENTARY
□ Sensation (location) □ W ithin normal level □ W NL except for:
□ Pulses (location) □ ecchymosis □ lesions □ bruises
□ Mucous membranes □ erythema □ rashes
□ IV lines □ pressure ulcer/grade/location
□ OTHER □ pressure relief device
□ incision (location) □ drains □ secretions
RESPIRATORY □ turgor
□ W ithin normal level □ W NL except for: □ OTHER
□ Irregular heart beat
□ shortness of breath □ dyspnea COMFORT
□ cough □ nasal flaring □ W ithin normal level □ W NL except for:
Breath sounds: □ pain location
□ unequal □ diminished □ pain characteristics
□ coarse/rhonchi □ crackles □ wheezes □ receiving: □ narcotics □ other analgesics
□ artificial airway
□ OTHER HYGIENE
□ shower
GASTROINTESTINAL □ bath
□ W ithin normal level □ W NL except for: □ mouthcare
□ NPO □ Diet □ TPN □ extraoral feeding □ pericare
□ Nausea □ Vomiting □ antiembolic hose
□ dysphagia □ gas eructation □ regurgitation □ OTHER
Abdomen:
□ firm PRECAUTIONS
□ tender □ falls
□ distended □ aspiration
Bowel sounds: □ neutropenia
□ hyperactive □ suicide
□ hypoactive □ airborne
□ absent □ seizure
Stool: □ radiation
□ no flatus □ OTHER
□ fecal incontinence □ constipation □ diarrhea
Stoma
□ Last BM □ OTHER
Name and Signature: