UNIVERSIDAD DE MANILA

Republic of the Philippines

City of Manila

COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF NURSING
NCM 101 - HEALTH ASSESSMENT – RLE
Name:_________________________________________ Year/Section:_______________
Instructor:______________________________________ Group: ________

THE NURSING HEALTH HISTORY

QUESTIONS DATA /FINDINGS NARRATIVE DOCUMENTATION

I. BIOGRAPHICAL DATA
Name:
Age:
Gender:
Birthday:
Nationality:
Ethnicity:
Address:
Religion:
Marital Status:
Occupation:
Place of Occupation:
Educational Attainment:
Caregiver/Support Person/SO
II. CHIEF COMPLAINTS
• “What is the reason for
seeking consultation?”

III. HISTORY OF PRESENT ILLNESS

a. Usual health pattern
b. Investigation of symptoms
(chronological story)
• Onset

• Course since onset

• Location

• Quality

• Quantity

• Setting

• Associated phenomena

• Alleviating or aggravating
factors
c. Relevant family information

d. Disability assessment

IV. PAST HEALTH HISTORY

a. Past general health

b. Childhood illnesses

c. Acute/Chronic Illnesses

Public service through quality education.

Justice Cecilia Muñoz – Palma corner Mayor Antonio J. Villegas Street Mehan Gardens, Ermita, Manila, Philippines 1000
Tel. Nos. (+632)5336-6582/(+632)5336-8956/(+632)5336-8966 Fax No.(+632)336-6554 www.udm.edu.ph
 UNIVERSIDAD DE MANILA
Republic of the Philippines
City of Manila

d. Accidents and disabling

injuries
e. Hospitalization/ Surgery

f. Immunization

g. Medication and transfusions

h. Allergies

i. OB History

V. FAMILY HEALTH HISTORY

blood relatives Genogram

spouse

children

VI. OCCUPATIONAL AND ENVIRONMENTAL HISTORY

VII. PSYCHOSOCIAL HISTORY

a. Smoking
(PY = Packs * Years)
b. Alcohol Intake
c. Use of illicit drugs
d. Food Habits
e. Recreational Activities
f. Social group affiliation
g. Cognitive abilities

Grading Criteria
Criteria Excellent Very Satisfactory Satisfactory Poor
16-20 11-15 6-10 1-5
Accuracy of Data
Completeness of Data
Organization and
Coherence
Grammar and
Mechanics
Clarity and Neatness
Subtotal

Total Score: ___________________

Conformed: Evaluated by:

___________________________________ ____________ _________________________________

Student Date: Instructor
Public service through quality education.
Justice Cecilia Muñoz – Palma corner Mayor Antonio J. Villegas Street Mehan Gardens, Ermita, Manila, Philippines 1000
Tel. Nos. (+632)5336-6582/(+632)5336-8956/(+632)5336-8966 Fax No.(+632)336-6554 www.udm.edu.ph