ADMISSION TO HOSPITAL

I. Identify / Biographic Data

1. Name :
Sure Name :
Given Name :
2. Place, Date of Birth :
Age :
3. Sex : Male Female
4. Job / Occupation :
5. Marital Status : Single Married Widower

Widow

6. Phone Number :
7. Religion : Islam Christian Buddha
Hindu Confucius etc
8. Adress :
9. Responsible Person
- Name :
- Relationship :
- Phone number :

II. Healthy History

1. Chief / Main Complaint

2. Present Health History

 3. Family Helath History
- Heredity diseases :
- Infections disease :
4. Past Helath History
- Diseases suffered from : Yes No
What kind of diseases :

- Surgery : Yes No
What kind of surgery :

III. Habbits
1. Smoking : Yes No
Lenght of time :
Amount of cigarattes :
2. Drinking coffee : Yes No
Lenght of time :
Amount of glasess :
3. Drinking Alcohol : Yes No
Lenght of time :
Amount of bottles :
Questions And Answers :

I. Identify / biographic data

1. Name
- May I know , what is your name ?
- Whats your name ?
- Your name, please ?
- Are you fajar name ?
- Can you give me your name ?
- Please say your name ?
- Could you tell me your name , please ?
- Can I get your name ?
Yes nurse, my name is Fajar
2. Place death of birth
- When were you born ?
- Where were you born ?
- Where is your birthday ?
- May I know, when were you born ?
- How old are you ?
- Could youtell me, how old are you ?
- Can you tell me, how old are you ?

I was born on june 6, 1963 ,I was born in Bukittinggi and I am 56 years old

3. Job
- What is your occupation ?
- What is your job ?
- What are you ?
- Whre do you work ?
- What is your brother job ?
My occupation is trade
4. Marital Status
- May I know , have you married ?
- Are you single ?
- Do you get married ?
5. Phone number
- Tell me your phone number, please ?
- What is your phone number ?
- Can I get your number ?
- What is your phone number that I can contact ?
My phone number is 082285143367
6. Religion
- What is your religion ?
I am Moslem
7. Address
- Where do you live ?
- What is your address ?
I live in Apel raya number 56 , Belimbing
8. Responsible person
- What is your responsible person name ?
she name is gina
- What is your relationship with her / him ?
She is my wife
- What is your phone number responsible person, please ?
081363096053

II. Health history

1. Main Complaint
- What is your complaint ?
- Can you tell me what your chief complaint ?
- why can you ben hospitalized?
- What is your reason to come to hospital ?
- why did you get hospitalized?
The client came on november 23, 2019 at 10 amthrought the emergency department
with complaints of shortness of breath , chest pain , cought with phlegm and dizzy
2. Present Health History
- What is your present health history ?
- What do you feel right now ?
- Could you tell me about your problem ?
 - Can you describe how do you feel right now ?
- What’s wrong with you ?
- What is the matter with you ?
- What are you feeling ?
Now , i feel shorthness of breath has diminished and not dizzy anymore
3. Family Health History
 Hereditary diseases
- Do you have your family member with hereditary diseases ?
- What kind of disease ?

my family that is my father has asthma

 Infectious disease
- Do you have your family member with infectious diseases ?
- What kind of disease ?
4. Past Health History
 Have you suffered from disease before ?
What kind of diease ?
 Have you had a surgery before ?
What kind of surgery have you had before ?
III. Habbits
1. Smoking
- Are you smoking ?
- Do you smoke ?
- Are you a smoke ?
Yes I am smoking

- How long have you been smoking ?

- How many years have you been smoking ?
10 years nurse
- How many cigarettes do you smoke ?
- How many packages of cigaratte ?

I pack of cigarettes a day

2. Drinking Coffee
- Do you drink coffee ?
yes I drink coffee

- How many years have you been drinking coffee ?

- How many long have you been drinking coffee ?
Since 5 years ago

- How many glass of coffee do you drink?

2 glasses a day

3. Drinking Alcohol
- Do you drink alcohol ?
- How many years have you been drinking alcohol ?
- How many long have you been drinking coffee
- How many bottles of alcohol do you drink ?