NURSING CARE HEALTH ASSESSMENT FORM

INSTRUCTIONS FOR COMPLETION

Please fill up the form below for the assessment of the client’s health status. Once we have all the required information,
assessment will be done accordingly. We will notify the client for further information.
If you have any inquiries, you can reach us at this phone number: 09123456789.

PART I. PATIENT INFORMATION to be completed IN FULL

Patient Name: _____________________________________________ Phone Number: _________________________

Last name First Name

Address: __________________________________________________________________________________________
Street Brgy. City or Town Province

Date of Birth: ____________________________ Sex: Male Female

Month Day Year
Religion: ______________________ Occupation: _________________ Contact No: ______________________
Marital Status: Married Separated Single others, please specify: __________________________________
Source of Referral: __________________________________________________________________________________

PART II. CHIEF COMPLAINT

Reason for seeking medical assistance: __________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________

PART III. HISTORY OF PRESENT ILLNESS

When did the problem started? ________________________________________________________________________

How bothersome is your problem? _____________________________________________________________________
Does it interfere with your activities of daily living? Yes No
Please specify the location of the problem: _______________________________________________________________
Does it radiate to a specific area of the body? Yes No
Have you tried any therapeutic maneuver to alleviate your condition? Yes No
If so, please specify: ________________________________ Did it make you feel better? Yes No
What were you doing when the problem started? __________________________________________________________
Do you feel any other symptoms besides your primary complaint? If so, please specify: ___________________________
__________________________________________________________________________________________________
If you are experiencing any pain, please fill up the form below:
Please describe the feeling you are feeling right now: _______________________________________________________
On a scale of 1 – 10 (10 as the highest), please rate the pain you are feeling right now:

PART IV: PAST HEALTH HISTORY

Previous hospitalizations:
Hospital: ___________________________________________________________________________________
Date: _______________________________________ Disease: _______________________________
Duration: ____________________________________ Attending Physician: _____________________
Remarks: ___________________________________________________________________________________
Have you had any surgeries before? Yes No
If so, please specify the details: ________________________________________________________________________
Drug History:

Name Dose(Route) Frequency Duration Remarks

Ex. Amlodipin 5mg once daily maintenance

Have you experience any kind of communicable disease in the past? Yes No
If so, please specify: ________________________________________
Major injuries: ________________________________ Food and drug allergies: ________________________

PART V: FAMILY HISTORY

Has anyone in your family had:

Disease/Condition YES NO Relationship

Diabetes
Hypertension
Heart Disease
Cancer
Mental Retardation
Tuberculosis
Influenza
Varicella (Chicken pox)
Measles
Asthma
Hepatitis
 PART VI: ENVIRONMENTAL HISTORY

WORK HISTORY:
Do you work full time? Yes No Student
How many hours per week? _____________________________
Describe your work/school:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Have you had any injuries or health problems in relation to your current occupation? If so, describe:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Are other workers similarly affected? Yes No
Is your work/school environment generally clean and safe? Yes No
If not, describe: _____________________________________________________________________________________
__________________________________________________________________________________________________

HOME EXPOSURE:
YE NO
 Do you use pesticides at your home? S

 Do you live near an industrial plant, commercial business, dump site, or nonresidential property?

 Have you ever changed your residence because of a health problem?

 Does your drinking water come from city water supply?
Grocery store
Water well
Others, specify: ____________
 Does your food come from somewhere other than a grocery store?
If yes, please specify: __________________________________
 Is anyone else in your home environment having similar symptoms to yours?
If yes, please describe: _________________________________________

PART VII: CURRENT HEALTH INFORMATION

Do you experience any sleep difficulty lately? Yes No

What are the factors that interrupts your sleeping pattern?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How many hours do you sleep at night? _________________________________________________________________
Do you take afternoon naps? Yes No
What foods do you usually eat?
__________________________________________________________________________________________________
How many meals do you have in a day? ______________

Please describe your daily routine

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How do you cope up with stress?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Do you usually visit the hospital for regular checkups? Yes No

PART VIII: PSYCOSOCIAL HISTORY

Do you experience any anxiety, depression, stress this past days? Yes No
If yes, state the factors that triggers this feeling: ___________________________________________________________
__________________________________________________________________________________________________
What methods or ways do you use to overcome or relieve this problem?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Is it effective? Yes No
What is your role in your family?
__________________________________________________________________________________________________
Does your family or friends help you whenever you have a problem? Yes No
Do you experience any violence within your family? Yes No

PART IX: INTERPERSONAL FACTORS

Ethnicity: _______________________ Spoken language: ____________________________________

Do you have any cultural belief about what you are feeling right now? Yes No
If yes, state what it is: ________________________________________________________________________________
Please describe your lifestyle (smoking, drugs, etc.):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What is strength for you?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Do you feel this right now? Yes No
Do you have concerns regarding your sexuality? Yes No
If yes, please elaborate further: ________________________________________________________________________
__________________________________________________________________________________________________

PART X: REVIEW OF SYSTEMS

Check each item accordingly:

Normal Abnormal Notes/Details

Skin
Ears
Head/Eyes
Nose
Mouth/Teeth
Throat/Neck
Lymphatic
Chest/Breast
Heart
Lungs
Abdomen
Endocrine
Genito/urinary
Rectal/pelvic
Extremities
Spine/other musculo-skeletal
Neurologic
Psychiatric
Additional Comments: