SAN PEDRO COLLEGE

NURSING HEALTH ASSESSMENT GUIDE

Part I – HEALTH HISTORY

I.BIOGRAPHICAL DATA
Name of Client: ___________________________________________________________Age:___________Gender:__________
Ward,Unit:___________________________________Bed No.:____________Examiner:_________________________________
Home Address:____________________________________________________________________________________________
Birth Date:_____________________Place of Birth:____________________Nationality:____________Marital Status:_________
Educational Level:_______________Occupation:_________________No. of Dependents:______Religion:__________________

II.CURRENT HEALTH STATUS

Chief Complaint:____________________________________________Impression:_____________________________________
Attending Physician:___________________________Date of Admission:__________Manner of Admisssion:________________
ASK ABOUT: Symptoms experienced__________________________________________________________________________
Onset:________________Duration:________________Frequency:___________________Severity:________________________
Region/Radiation/Related Symptoms:________________________________Precipitating/Palliative Factors:________________
Remedies Given?Initial Treatment ( Before Consultation):_________________________________________________________
Consultation made When:__________________________Where:_______________________Whom:______________________

Notes:

III.PAST HEALTH HISTORY

Personal/Medical History
Arthritis Cancer Depression Diabetes Asthma/ Lung Problem
Heart Disease High Blood Pressure Psychiatric Disease Stroke Thyroid Problem
Epilepsy/Seizure Serious Injuries: (fractures, head injuries,motor accidents, burns, or lacerations)
Other/remarks:___________________________________________________________________________________________
Past Surgical Procedures: Please list previous surgeries with appropriate dates
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Previous Hospitalization/Visits
Reasons of Seeking Care: ___________________________________________Appropriate Date:________________________
Hospital/Health Institution: __________________________________________Physician:_______________________________
Treatment:_______________________________________________________________________________________________
Childhood Illnesses
Mumps Chicken pox Measles Poliomyelitis Ear Infections
Tonsillitis Asthma Diphtheria Others:_________________________________________
Medications: Prescription and non prescription medicines, vitamins, home remedies, birth control pills, herbs,etc.
Name of Drug Medication Dose (e.g mg/pill) How many times a day
_________________________ ______________________________________ _____________________________________
_________________________ ______________________________________ _____________________________________
_________________________ ______________________________________ _____________________________________
Allergies or Drug Reactions: ________________________________________________________________________________
Immunizations: (Childhood)
BCG Hepatitis B DPT OPV Measles Others:________________________
Date of Recent Immunizations
Hepatitis A__________Hepatitis B__________Influenza(flu)__________Varicella__________HPV__________HTIG___________
Tetanus Toxioid__________Pneumonia__________others:________________________________________________________
Allergies: Please list any known allergies:_______________________________________________________________________
Other Concerns
Tobacco Use Cigarettes Never Quit Date:_____________________________________
Current Smoker: Packs/day:_______________No. of Years:________________________________
Alcohol Use Do you drink alcohol? No Yes, No. of drinks per week:__________________________
Drug Use Do you use recreational drugs? No Yes
Have you ever used needles to inject drugs? No Yes
 Sexual activity: Sexually active? Yes No Not Currently
Current Sex Partner(s) is/are: Male Female
Birth Control Method:______________________________________ None Needed
Have you ever had any sexually transmitted diseases (STDs)? No Yes, specify:_____________

Notes:

IV.FAMILY HISTORY
BROTHERS/SISTERS Gender Birthdate Decease Cause of Death Genetically linked/ Details
(include half-siblings) (M/F) d Common Diseases

MATERNAL SIDE
MOTHER GENDER BDATE Deceased Cause of Death Genetically linked/ Details
Common Diseases

GRANDMOTHER

GRANDFATHER

AUNT & UNCLES

FIRST COUSINS

PATERNAL SIDE
FATHER Gender BDATE Deceased Cause of Death Genetically Linked/ Details
Common Diseases

GRANDMOTHER

GRANDFATHER

AUNT & UNCLES

FIRST COUSINS
 V.GORDON’S FUNCTIONAL HEALTH PATTERNS  please follow provided for
A. Health Perception Pattern
B. Nutritional/ Metabolic Pattern
C. Elimination Pattern
D. Sleep/ Rest Pattern
E. Activity/Exercise Pattern
F. Cognitive/Perceptual Pattern
G. Values/Belief Pattern
H. Self-Perception/ Self-Concept Pattern
I. Roles/Relationship Pattern
J. Sexuality/Reproductive Pattern
K. Coping / Stress Tolerance Pattern

Note: Genetically-linked Diseases; Common Diseases- birth defects, specify—premature births –mental retardation, specify—diabetes—hearing loss—heart disease—seizures—
allergies—arthritis—obesity—cancer, specify