_DF-002

MSU-Iligan Institute of Technology August 2016

College of Nursing PN-1/Ward

NURSING HEALTH ASSESSMENT I

Student Name: __________________________________ Date/s of Care: _______________ Score: _________

Area of Assignment: __________________________ Clinical Instructor: ________________________________

DEMOGRAPHIC DATA

Name: ________________________________________ Age: _________ Sex: __________ Status: _________

Address: ______________________________________ Religion: __________ Occupation: ________________

HEALTH HISTORY
A. Chief Complaint/s:

B. Impression/Admitting Diagnosis:

C. History of Present Illness: (Location, onset, character, intensity, duration, aggravation and alleviation, associated
symptoms, previous treatment and result, social and vocational responsibilities)

D. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious disease, immunization/ health
maintenance, major illness, allergies, medication, habits, birth and development history, nutrition – for pedia)

E. Health Habits
Kind Frequency Amount Period
1. Tobacco
2. Alcohol
3. OTC drugs

F. Family History with Genogram

History of Heredo-familial diseases: Genogram (up to 3rd generation)
____ Cancer Legend:
____ DM
____ Asthma
____ Hypertension
____ Cardiac Disease
____ Mental Disorder
____ Others: _____________

G. Patient’s Perception
Present Illness:

Hospital Environment:

H. Summary of Interaction

Patient’s Name / Room No. | 1