PATIENT’S PROFILE

DEMOGRAPHIC DATA

Patient’s name:
Sex:
Birthdate:
Age:
Time and date of admission:
Attending physician:
Birthplace:
Permanent Address:
Nationality:
Religion:
Marital Status:
Occupation:
Health Care Financing:
Source of Medical Care:
Diagnosis:

CURRENT HEALTH STATUS

C
O
L
D
S
P
A

PAST MEDICAL HISTORY

Problems @ birth:
Childhood illnesses:
Immunizations to date:
Adult illnesses (physical, emotional, mental)
Surgeries:
Accidents:
Prolonged pain or pain patterns:
Allergies:
Physical, emotional, social or spiritual weakness:
Physical, emotional, social or spiritual strength:

FAMILY HEALTH HISTORY

Age of parents (living? Date of death):
Parents’ illness and longevity:
Grandparents’ illness and longevity:
Aunts’ and uncles’ ages, illness, and longevity:
Children’s ages, illness or handicaps and longevity:

GYNECOLOGIC HISTORY

Age when patient had her menarche:

Period length:
Cycle length
Pregnancy info (kamo nla bahala sisz)
GTPALM:

LIFESTYLE AND HEALTH PRACTICES

Description of a typical day (am to pm)
Nutrition and weight management:
24-hour food recall
Who purchases and prepares meals
Activities on a typical day:
Exercise habits and patterns:
Use of medications and other substances:
Self concept:
Self responsibilities:
Social activities for fun and relaxation:
Type of work, level of job satisfaction, work stressors
Finances:
Stressors in life and coping strategies used:
Residency, type of environment, neighborhood, environmental risks:

PSYCHOSOCIAL HISTORY
(Refer to chapter 7, Health Assessment book: Weber&Kelley, 6 th edition)