HOLY NAME UNIVERSITY

OFFICE OF NURSING
City of Tagbilaran

HEALTH-STATE PROFILE / NURSING HISTORY

I. PERSONAL DATA
Name: ___________ Age: _____ Sex: _____ C/S: ______
Address: _______________________________
Educational Attainment: ________________________
Occupation: ______________________
II. PAST HISTORY
Development History
Development Task Theory (by Robert Haveghurst)

Psychological Development Theory 9by Erick Erickson)

B. Illness in the Past

Childhood

Adolescent

3. Adulthood

C. Travels (illness experienced during travel)

D. Accidents Trauma:

III. FAMILY HISTORY

If single:

Father’s Name: _______________________ Age: _____

Occupation: _______________________

Siblings: Name

Siblings: Name Sex Biological Relation to the Patient

_____________________ _______ ________________________
_____________________ _______ ________________________
_____________________ _______ ________________________
_____________________ _______ ________________________
_____________________ _______ ________________________

If married:
 Name of Spouse: ______________________ Age: _____
Occupation: _________________________

Children: Name Sex Biological Relation to the Patient

_____________________
_____________________
_____________________
_____________________
_____________________
Heredo-familial Disease:
Diceassed Family Member:
_______ ________________________
_______ ________________________
_______ ________________________
_______ ________________________
_______ ________________________

IV. VITAL INFORMATION

A. Present Hospitalization:
Date Admitted: ____________ Ward: _________ Bed No.: _______
Chief Complaint: ___________________________
Medical Diagnosis: ___________________________
Surgery (if any): ____________________________

B. Previous Hospitalization:
Date of Hospital Experience: _________________________
Causes of Hospitalization: __________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

Medical Intervention: ______________________________________

_______________________________________________________
_______________________________________________________
_______________________________________________________

Condition upon discharge: __________________________________

_______________________________________________________

C. Vital Signs (present / upon interview):

Temperature: ______ Pulse: ______ Respiration: ______
Blood Pressure: ________ Heart Rate: _______ Pupils: ________
Height: __________ Weight (before illness): ___________
Weight (at present): ___________
D. Informant:
Patient: __________________ Relationship: _____________
Significant Others: ____________________

V. PERCEPTIONS AND EXPECTATIONS OR PRESENT ILLNESS

1. Why did you come to the hospital?

_______________________________________________________
2. What in your opinion caused you to get sick?

_______________________________________________________
3. What do you expect to stay in the hospital?

_______________________________________________________
4. How long do you expect to stay in the hospital?
_______________________________________________________
 5. With whom do you live?
_______________________________________________________
6. Are any of your family close friends able to visit you here in the hospital?
_______________________________________________________
7. How do you expect to get along after you leave the hospital?

 PERCEPTIONS ABOUT TECHNOLOGY

1. Are you comfortable with using hospital technology?

__ YES __ NO
2. Are you able to cope up with the technology being introduced to
you?
__ YES __ NO
3. Do you use any medical device at home? Please specify.
______________________________________________

VI. HABITS OF DAILY LIVING

1. Food Habits
a. Meal Patterns:
Time Usual Food
Breakfast ______________ ________________
Lunch ______________ ________________
Dinner ______________ ________________
Snacks ______________ ________________
b. Food dislikes: _____________________________________
c. Food Allergies: ____________________________________
2. Fluid Habits
a. Fluid Preferences: _________________________________
b. Fluid Dislikes: _____________________________________
3. Sleep Habits: ___________ At home: _________ Hospital: ________
a. Usual bedtime: ________________________
b. Usual number of hours of sleep: ____________________
c. Get up at night? ____________ (if yes, why) _________________
________________________________________________________

d. Nap Habits: Yes: _____________ No: ______________

If yes, what time of the day? _______________________________
4. General Hygiene:
a. Bathing Usual Time Frequency
At home: __________________ ________________
Hospital __________________ ________________
b. Care of Teeth:
Type: Natural __________________ ________________
Dentures __________________ ________________
 5. Elimination:
a. Bowel Habits:
At home: __________________ ________________
Hospital: __________________ ________________
b. Irregularities:
Present Past
Yes No Yes No
Constipation: _______ _______ ______ _______
Fecal Impaction_______ _______ ______ _______
Diarrhea _______ _______ ______ _______
Fecal Incontinence_______ _______ ______ _______
c. Bladder Habits: Usual Time Frequency
At home _______________ _______________
Hospital _______________ _______________

d. Irregularities
Present Past
Yes No Yes No
Dysuria? _______ _______ ______ _______
Frequency? _______ _______ ______ _______
Nocturia? _______ _______ ______ _______
Anuria? _______ _______ ______ _______
Polyuria? _______ _______ ______ _______
Oliguria? _______ _______ ______ _______
Retention? _______ _______ ______ _______
Incontinence? _______ _______ ______ _______
Hematuria? _______ _______ ______ _______
Pyuria? _______ _______ ______ _______
Proteinuria? _______ _______ ______ _______
Glycosuria? _______ _______ ______ _______

VII. COMMUNICATION/ CULTURE

/+

1. Language Spoken:
____________________________________________
2. Religion : _________________________________________________
3. Ethnicity : _________________________________________________
4. Food or things which aren’t allowed by your culture:
_________________________________________________________
5. Communication problem with hospital staff: Yes: _______ No: _______
If yes, elaborate:___________________________________________
________________________________________________________
6. Needs / Complaints attended? Yes: _______ No: _________
Specify: __________________________________________________
Outcome: _________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

VIII. LABORATORY

Name of Exam / Normal Value Clinical Nursing

Results Significance Responsibility
IX. NURSE IMPRESSION

1. General Body Structure:

Body Built: _______ Thin ________ Long Bony Structure
_______ Broad ________ Short Bony Structure
Physical Bearing:
Posture: _______ Lordotic ________ Kypholic
_______ Scoliotic ________ Normal
Gait: _______ Hemiplegic-leg is stiff and extended foot is lifted and
leg swung at pelvic level; arm drag not swing
_______ Steppage - elevating hip and knee excessively high
to lift drap foot off ground
_______ Dystopic – legs far apart shifting of weight from side
to side like waddling, abdomen, is often protacting and lordosis is
common
_______ Tabetic – legs positioned far apart, lifted high, and
forcibly brought down with such step, stamping heel on ground.

_______ Cerebellar – staggering gait with lurching from side

to side
_______ Parkensonian – shuffling gait with short steps; head
is hunched forward
_______ Dystonic – jerky dancing movements that appear
non-directional
_______ Astasia – uncontrolled falling
_______ Normal

2. Emotional Status
_______ Happy _______ Angry
_______ Depressed _______ Anxious
_______ Agitated _______ Scared

_______ Isolent _______ Drowsy

3. Mental Status
_______ Lethargic _______ Delirious
_______ Stuparous _______ Confused
_______ Tense _______ Incoherent
_______ Hysterical _______ Apprehensive
_______ Hallucinations _______ Disoriented
_______ Normal
4. Summary of Patient’s Present Condition Significant to Nursing Care:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________