University of the Philippines Manila

SCHOOL OF HEALTH SCIENCES

Extension Campus, Baler, Aurora
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PATIENT ASSESSMENT
I- PATIENT PROFILE
Name: Educational Attainment:
Age: Occupation:
Sex: Religion
Status:
Address: Date & Time Admitted:
Chief Complaints:

Attending Physician:
Diagnosis/Impression:

I- II - HEALTH HISTORY

Present Illness
Chief Complaints.
A narrative account of the problem for which the patient is seeking care. Describe the onset of the
problem. How and when did it start. What was the setting or what was the patient doing at the
time of onset? What were its manifestations? Describe principal symptoms in terms of location,
quality, quantity or severity, timing, onset, duration and frequency, factors that aggravate or relieve
symptoms, associated manifestations. What treatment was taken at home? How did the patient
respond?

Past Health History

General state of health.

Childhood illnesses experiences (measles, mumps, chicken pox etc.)
Immunizations like measles, DPT, Pentavalent, Polio etc.
Adult illnesses. Type, how it was treated, recovered or not.
Operations, injuries, allergies.
Current medications taken, including home remedies.

Family History
Illnesses experienced by other members of the family. Age and health or age and cause of death.
Occurrence within the family of any of the following conditions: diabetes, tuberculosis, arthritis,
anemia, mental illness, heart disease etc.

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For pediatric patients add:

Birth History

Prenatal. Maternal health before/during pregnancy. Illnesses experienced by mother during

pregnancy, complications, drugs taken. Duration of pregnancy.

Natal. Nature of labor and delivery. Birth order. Birth weight.

Feeding History (may also be written under food and fluid intake)

Infancy
Breastfeeding – frequency and duration of feeds; use of complementary or supplementary artificial
feedings; difficulties encountered; timing and method of weaning. Artificial feeding – type of
formula, concentration, amount and frequency of foods, feeding difficulties; timing and method of
weaning. Vitamin supplements given, supplementary feeding – types and amount of food given,
when (age) introduced, infant’s response.

Growth and Development History

Height and weight at birth, ages 1,2,5, and 10 years. History of rapid or slow gains or losses in
weight. Tooth eruption and loss pattern. Developmental milestones like ages at which the patient
held up his head in a prone position, rolled from front to back, sat with support/alone, walked, etc.
Social development – sleep patterns, toilet training (age, methods used, difficulties encountered,
terms used for defecation and urination). Speech (hesitation, stuttering, baby talk lisping,
estimated number of vocabulary). Habits – headbanging, thumbsucking, nailbiting, pica, ritualistic
behavior, tantrums, aggression, withdrawal. Schooling – age entered school, achievement.
Personality – degree of independence, relationship with parents/sibling, activities and interests,
special friends, major assets and skills.

III – REACTIONS AND EXPECTATIONS

History of previous hospitalizations. Data. Reason. Condition of discharge. Reactions to

hospitalization – staff quality of care received. What does the patient expect from this
hospitalization? What charges does he expect to happen? What would he like to know about his
treatment?

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IV – PATTERNS OF FUNCTIONING AND CLINICAL INSPECTION (Physical Assessment)
Patterns of functioning
1. Respiratory
 History of cough, colds,
asthma, PTB, difficulty of
breathing, etc. Cough?
Productive, frequency,
usual precipitating factors.
 What are the usual
measures taken for relief?
 Does he/she smoke? Type.
Number of packs
consumed per day for how
long has he/she been
smoking?
2. Circulatory
 History of hypertension,
dizziness, fainting spells,
palpitations, chest pain
etc.
 Relief measures done
 Causes of attacks
 Swelling, discolorations,
edema experienced?
What was it associated
with?
3. Food & Fluid Intake
 Usual foods taken
 Meal patter –how many
meals does he/she take
each day? Time?
 Food allergies
 Food preferences &
dislikes
 Number of glasses of
water taken each day
 Other beverages taken
 Does he/she take
alcoholic beverages?
Type, average amount
consumed/session,
frequency, for how long
has he/she been
drinking?
 Pedia patients: Include
feeding history
Clinical Inspection Other Sources
RR- Characterize; rate, rhythm, Results of chest X-ray
symmetry & depth & effort of Results of sputum
breathing, use of accessory muscles, examinations
breathing patterns. Contour of the Medications being taken
chest. Breath sounds? Rate? Cough?
Nature, frequency, does it interfere
with rest? Sputum? Nature,
appearance. Colds? Sneezing?
Nasal discharges? Tracheostomy?
Other respiratory aids used.
BP, HR, PR (Characterize) Presence ECG results
of swollen or discolored parts? Blood Chemistry
Cyanosis? Pallor, cold extremities? Hematology
Edema? Pitting, where? Medications taken
Circumference of edematous
extremities? Redness in pressure
areas. Complaints of headache?
Nature, severity, location associated
symptoms. Chest pain? Location,
severity, quality. Easy fatigability,
palpitations, tightness of chest
mucus.
Color of nailbeds and mucus
membranes.
General state of health, body, build, Diet prescribed
nutritional state. Fluids prescribed (oral,
Height and weight Nutritional status parenteral)
of skin, scalp, nails, color and Is the patient on I and O
texture of skin. Results of:
Hydration of mucus membranes GI tract X-rays, liver
Condition of mouth, lips and gums function tests blood sugar
Presence of dentures. level
Appetite, actual foods taken
(quality/quantity). Type and rate of
IVF or other parenteral feedings.
Presence of NGT. Complaint of:
vomiting nature, amount, frequency,
precipitating factors. Abdominal
pain-nature &u severity. Dysphagia,
Nausea?
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4. Elimination
 How many times does the
patient void/day
 Usual characteristics of
urine, color, amount
 Any dysuria? Dibbling
 How many times does the
patient have BM/day?
Usual time?
 Characteristics of stools?
 Does he/she take any aids
for elimination?
 Diarrhea? Constipation?
Frequency, causes, relief
measures
5. Regulatory Mechanisms
 Has he/she had fever
before? What was it
associated with? Any
chills?
 What relief measures
were done
 Menarche, interval,
number of days, LMP
 Menopause? Hot
flushes
 Birth control pills
taken? Hormonal
replacement taken
 EDC, onset of
contractions? Have
membranes ruptured
6. Hygiene  often
 How often does the
patient take a bath?
Time of day?
 How often doe he/she
shampoo? Brush his
teeth? Change clothes,
etc.
 Any allergies to
soap/shampoo?
 Any belief/practices
related to personal
hygiene
Frequency, amount, appearance of Results of Upper
urine, feces, perspiration. Gastrointestinal series,
Contour of abdomen. barium edema, etc. stool
Passage pf flatus? Abdominal exam result, urinalysis
distention? Tenderness? Hernia? result, kidney functions
Sounds in the abdomen. tests.
Constipation? How many days?
Diarrhea? Frequency?
Characteristics of feces. Melena?
Quantity, Hematemesis? Amount &
frequency. Urinary catch?
Colostomy? Abnormalities of anus,
surrounding, skin and anus.
Temperature (oral, rectal, or Results of blood exam
axillary) indicative of an infection
Moiture and color of skin – dry, process
moist? Wet with perspiration? Medications taken
Face –flushed, rashes? Twitching?
Paralysis?
Contractions? Duration &
frequency. Intact membranes?
Vaginal bleeding? Height &
firmness of fundus.
Amount & appearance of lochia,
breast enlargement, tenderness, state
of nipples. Appearance of perineal
area. Characteristics of male/female
genitalia
General appearance; neat, dirty,
unkempt
Skin condition- scars? Lesions?
Head: Hair- distribution and texture
Scalp- secretions? Lesions?
Dandruff? Pediculosis?
Skull –contour, size
Nails: clean or dirty? Short or long?
Mouth: clean? Odors (halitosis)
Does the patient have any
unpleasant odor?
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7. Exercise & locomotion Physical bearing: stature, gait, Result of x-ray for
 Usual exercise at home, posture, movement. Extent of range fractures, dislocations
frequency, time done, of joint motion? Lab results that would
amount Limitations of movements? signify musculoskeletal
 Joint stiffness Fracture? Joint stiffness? abnormalities
experienced? Contractures deformities?
 History of gout? Dislocations? Muscle pain?
Arthritis? Cramps? Amputated parts? Use of
 Is there any paralysis? crutches, cane or other walking aids
 Does he/she use Neck: symmetry of musculature,
prosthetic devised? Aids abnormal masses, swelling,
to mobility? enlargement of thyroid glands,
 Is any part of his/her body presence of lymph nodes, vein
paralyzed? Since when? prominence, scars, moles, stiffness
of neck?
8. Rest and sleep Does the patient look tired? Sleepy? Rest prescription of
 Number of hours usually Are there bags under the eyes? physician
slept? Time of arising and Actual number of hours slept?
retiring? Nature of sleep? Interrupted?
 Any insomnia? Difficulty in sleeping? Possible
 Does he/she take daytime cause
naps, for how long?
 Favorite sleeping
position?
 Number of pillows used?
 Does he use a mosquito
net?
 Bedtime rituals?
 What interferes with
sleep?
9. Communication and special Eye: Distibution of eyelashes, Results of sight and
senses condition of eyelids, color of sclera? hearing tests
 R or L handed? Dryness or lacrimation?
 Does the patient use Characterize conjunctiva, pupils,
eyeglasses? Hearing eye control and movement, lens.
aids? Presence of ulcerations, abrasions,
 For how long has the foreign body, growth, eye
patient been having infections, catarrh.
these? Ears: shape of pinna, lesions,
 Is there any visual- swelling, tenderness of mastoid
auditory disturbances? process? External canal discharges?
 Are there speech Foreign bodies lesions? Earache?
disturbances? Difficulty of hearing?
 Dialect or language Nose: patency, condition of septum
spoken? and turbinates, adenoids? Epistaxis?
Voice: manner of talking
Mannerisms: Coherence of
expressions; presence of glasses
contact lenses, hearing aids
Speech defects

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10. Sensory Orientation to time? Place? Self? Results of neurologic
 History of convulsions Others? tests
 History of loss of Has the patient suffered seizures
consciousness while in your care?
 History of epilepsy, Level of consciousness. State of
onset at what age? awareness. Response to stimuli-
 Medications taken tactile? Verbal (coherence of
expression) pressure, thermal,
pain.
11. Pain & Discomfort Describe physical manifestations Check physician record
 Pain or discomfort of pain or discomfort present. for symptoms of which
frequently experienced Nature, duration extent of pain or the patient complains.
 Describe other discomforts. Medications taken
manifestations Muscle guarding due to pain?
 What is done for relief? How does pain affect other
 Does he/she know the patterns, (example rest)
cause describe
12. Recreation/Diversion Any evidence of boredom? What
 What is done for fun? does he/she want to do to pass
Hobbies? his/her time?
 Interest he/she would
like to pursue?
 (Children) What is
their favorite
plaything?
13. Religious Life Religious medal worn. Need for
 Religious affiliation a religious counselor. Ability to
 Religious beliefs & meet own spiritual needs
practices (esp.those
may affect his/her
care & health), diet,
days of worship, holy
days
14. Coping Mechanisms What are the patient’s attitudes? Reports of psychiatric
 What is done when What is his/her mood? evaluations
facing stressful How is he/she coping with his
situations? What do illness
you do when angry? Coping mechanisms observed
Frightened? during stressful circumstances.
 Whose advice is Postnatal patients: Response to
sought when motherhood
problems occur? Ways of handling baby

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15. Social/Occupational Support of family/friends Check social history
 Work/role –type and Behavior towards roommates, regarding social,
hours of work visitors, staff occupational problems
 Feelings about his/her Acceptance of sick role or other
works role change
 Family roles? Need for teaching and counseling
 Members of
household
 Social roles?
 Anybody special
he/she wants to see
 Cultural prescriptions
regarding health care
and practices

COMPETENCIES:
1. Physical - orientation to environment
-ability to care for himself
-ability of family members to care for patient and carry out instructions for
care
2. Social -how is the relationship between the patient and his family?
-how does the patient relate to other people?
-is the patient the breadwinner/homemaker?
-is he the decision-maker?
3. Emotional -how stable are the patient's emotions?
-is he/she susceptible to mood swings
-how responsible is he/she for his/her behavior?
4. Environmental-how accessible to transportation?
-how far is the home from the nearest hospital, clinic, or health center?
-are there possible hazards at home? (example, squatter area, prone to fires)
5. Mental -ability to understand, relate cause to effect, solve problems, communicate
with others, recall events
-educational background