BETHLEHEM UNIVERSITY

FACULTY OF NURSING & HEALTH SCIENCES

Data Collection Sheet

NURS 252 / Fall 2020

Pt. Name Student Name

Age Date of Admission
Sex Informant
Date Room/ No.
Occupation Height
Marital Status Weight

Medical Diagnosis: _________________________________________________

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Patient Chief Complaint: ______________________________________________

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History of present illness: _____________________________________________

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Past Medical History: :_______________________________________________

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Family History:_____________________________________________________
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Nutritional History: :_________________________________________________

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Life Style and Habits: _______________________________________________

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Allergies: :_________________________________________________________
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General Appearance: :________________________________________________

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Skin:_____________________________________________________________
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Head: ____________________________________________________________
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Face:
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Neck: ____________________________________________________________
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Eyes: ____________________________________________________________
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Ears: _____________________________________________________________
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Nose: ____________________________________________________________
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Mouth & throat: ____________________________________________________

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Chest & Lungs: ____________________________________________________

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Heart & circulatory system: ___________________________________________
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Abdomen_________________________________________________________
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Genitourinary system:_______________________________________________
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Neurological System:________________________________________________
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Musculo-skeletal System:____________________________________________
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Social Environmental:_______________________________________________
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Laboratory Examination:
Test Date Patients’ Value Normal Value Interpretation

Medication
Drug Name Dose Uses Rationale Contra- Side Effects
Indications
Patient Problems Nursing Action Rational Evaluation