CLIENT’S INFORMATION SHEET

Be it known to all concerned that the information below will be treated with privacy and confidentiality.

NAME: (Optional)_______________________________________________ DATE: _______________________

ADDRESS: __________________________________________________________________________________________________
BIRTHDATE: ________________________________________________ AGE: _______________________
CONTACT No.: (Optional) __________________________________ CIVIL STATUS: _______________
PHILHEALTH MEMBER: YES NO
ATTENDING PHYSICIAN: (Optional) ___________________________________
PEDIATRICIAN: (Optional) ____________________________________________
BIRTHING FACILITY: _________________________________________________________________________________________

MENSTRUAL HISTORY OBSTETRICAL SCORING

MENARCH: _______________________ G P T P A L
LMP: _____________________________

Please detail all pregnancies in order.

Your periods occur every ______________ days and last DATE OF AOG AT THE TIME OF TYPE OF PLACE OF
# GENDER ANESTHESIA
for ___________ days. DELIVERY DELIVERY DELIVERY DELIVERY

ANY PROBLEM WITH YOUR PERIODS? YES NO

HEAVY FLOW CLOTS IRRREGULAR
PAIN/CRAMPING DISCHARGE
BLEEDING BETWEEN PERIODS
EDD: FETAL BACK:
OTHERS: _______________________________________
AOG: PRESENTATION:
FHT: FUNDIC HEIGHT:

GYNECOLOGICAL HISTORY CONTRACEPTIVE HISTORY

Have you had any of the following? (Check ALL that apply) Are you currently sexually active?
YES NO NEVER BEEN
Abnormal Pap Smear Ovarian cyst
Infertility Chronic Pelvic Pain
Previously used Birth control method (Check ALL that apply)
PID Genital Warts Birth Control Pill
Recurrent vaginitis Pain in Intercourse Condoms
Diaphragms
Urinary Incontinence Recurrent Miscarriage
DepoProvera
Breast pain UTI
IUD
Endometriosis Uterine Fibroids Spermicide
STD: Other: ________________________________________
None of the above No previous birth control

Any problems with previous method? NO

YES: ____________________________________________
PREVENTIVE CARE HISTORY
VACCINATIONS (YEAR)
LAST PAP SMEAR DATE: NORMAL ABNORMAL FLU SHOT
LAST MAMMOGRAM DATE: NORMAL ABNORMAL TDAP VACCINE
LAST CHOLESTEROL TEST DATE: NORMAL ABNORMAL TETANUS-DIPHTERIA
LAST CBC TEST DATE: NORMAL ABNORMAL VARICELLA VACCINE
LAST BP SCREENING: NORMAL ABNORMAL HEPATITIS VACCINE
LAST BONE DENSITY TEST: NORMAL ABNORMAL MMR VACCINE
LAST DIABETES SCREENING: NORMAL ABNORMAL

SURGICAL HISTORY (Please list all surgical procedures) NONE

SURGERY: ____________________________________________________________ DATE: ________________________

SURGERY: ____________________________________________________________ DATE: ________________________
SURGERY: ____________________________________________________________ DATE: ________________________
SURGERY: ____________________________________________________________ DATE: ________________________
SURGERY: ____________________________________________________________ DATE: ________________________

CURRENT MEDICATION HISTORY (Please include current prescriptions and medications ONLY)

DRUG NAME: ____________________________________________________________ DOSE: _______________________

DRUG NAME: ____________________________________________________________ DOSE: _______________________
DRUG NAME: ____________________________________________________________ DOSE: _______________________
DRUG NAME: ____________________________________________________________ DOSE: _______________________
DRUG NAME: ____________________________________________________________ DOSE: _______________________

ALLERGY HISTORY (Please list all surgical procedures) NONE

ALLERGY: _______________________________________________________ REACTION: ________________________

ALLERGY: _______________________________________________________ REACTION: ________________________
ALLERGY: _________________________________________________________ REACTION: ________________________
ALLERGY: _________________________________________________________ REACTION: ________________________
ALLERGY: _________________________________________________________ REACTION: ________________________

SOCIAL AND LIFESTYLE HISTORY

CIGARETTE SMOKER NEVER FORMER CURRENT-AMT/DAY __________________

ALCOHOL USE NO YES IF YES, AMT/WK ______________________
CAFFEINE USE NO YES IF YES, AMT/DAY _____________________
DOMESTIC ABUSE NO YES IF YES, CURRENT or PAST
REGULAR EXERCISE NO YES TYPE: _____________ AMT/WK __________
MONTHLY BREAST EXAM NO YES
HAVE YOU HAD CHICKENPOX NO YES
STREET DRUGS/MARIJUANA USE NO YES
DO YOU HAVE A HEALTH CARE DIRECTIVE (LIVING WILL) NO YES
PAST MEDICAL HISTORY Indicate Relationship EXPERIENCING TODAY/RECENTLY
ANEMIA SELF FAMILY →
Review of Systems
ANXIETY SELF FAMILY →
FEVER YES NO
ASTHMA SELF FAMILY →
CHILLS YES NO
BLOOD CLOTTING DISORDER SELF FAMILY →
SWEATS YES NO
CANCER; BREAST SELF FAMILY → CONSTITUTIONAL
WEIGHT LOSS YES NO
CANCER; CERVICAL SELF FAMILY → WEIGHT GAIN YES NO
CANCER; COLON SELF FAMILY → FATIGUE YES NO

CANCER; OVARIAN SELF FAMILY → EYES IMPAIRED VISION YES NO

CANCER; SKIN-TYPE: __________ SELF FAMILY → HEAD, EARS, NOSE, & HEADACHES YES NO
THROAT SINUS CONGESTION YES NO
CANCER; UTERINE SELF FAMILY →

LUMPS YES NO
CANCER; OTHER: _____________ SELF FAMILY →
TENDERNESS YES NO
CARDIAC ARRYTHMIA SELF FAMILY → BREAST
SWELLING YES NO
CORONARY ARTERY DISEASE SELF FAMILY →
NIPPLE DISCHARGE YES NO
CROHN’S DISEASE SELF FAMILY →
CHEST PAIN YES NO
CYSTIC FIBROSIS SELF FAMILY → CARDIOVASCULAR
LOSS OF CONSCIOUSNESS YES NO
DEEP VEIN THROMBOSIS (DVT) SELF FAMILY →
SHORTNESS OF BREATH YES NO
DEPRESSION SELF FAMILY →
RESPIRATORY WHEEZING YES NO
DIABETES TYPE: ______________ SELF FAMILY → COUGH YES NO
EATING DISORDER: ___________ SELF FAMILY → NAUSEA YES NO

GASTRIC ULCER SELF FAMILY → VOMITING YES NO

GERD SELF FAMILY → GASTROINTESTINAL DIARRHEA YES NO

GESTATIONAL DIABETES SELF FAMILY → CONSTIPATION YES NO

BLOOD IN STOOLS YES NO

HEPATITIS– TYPE: ____________ SELF FAMILY →
URINARY URGENCY YES NO
HYPERLIPIDEMIA SELF FAMILY →
URINARY FREQUENCY YES NO
HYPERTENSION SELF FAMILY → GENITOURINARY
URINARY INCONTINENCE YES NO
IRRITABLE BOWEL SYNDROME SELF FAMILY →
BLOOD IN URINE YES NO
KIDNEY STONES SELF FAMILY →
RASH YES NO
LUPUS SELF FAMILY →
INTEGUMENTARY CHANGE IN MOLES, LESION YES NO
MIGRAINES SELF FAMILY →
CHANGE IN HAIR GROWTH/LOSS YES NO
MULTIPLE SCLEROSIS SELF FAMILY → MUSCULAR WEAKNESS YES NO
OSTEOPOROSIS SELF FAMILY → NEUROLOGIC INCOORDINATION YES NO

PARKINSON’S DISEASE SELF FAMILY → TINGLING OR NUMBNESS YES NO

PULMONARY EMBOLISM SELF FAMILY → JOINT PAIN YES NO

MUSCULOSKELETAL
RHEUMATOID ARTHRITIS SELF FAMILY → MUSCLE PAIN YES NO

EXCESSIVE THIRST YES NO

SCOLIOSIS SELF FAMILY →
ENDOCRINE EXCESSIVE URINATION YES NO
SEIZURES SELF FAMILY →
TEMPERATURE INTOLERANCE YES NO
SICKLE-CELL DISEASE SELF FAMILY →
ANXIETY YES NO
SLEEP APNEA/DISORDER SELF FAMILY →
DEPRESSION YES NO
STROKE SELF FAMILY →
PSYCHIATRIC FEELING CONFUSED YES NO
THYROID DISORDER-TYPE: _____ SELF FAMILY →
DIFFICULTY SLEEPING YES NO
TUBERCULOSIS SELF FAMILY →
EXCESSSIVE ANGER YES NO
ULCERATIVE COLITIS SELF FAMILY → EASY BLEEDING YES NO
Other Medical History we should know about: HEME-LYMPH EASY BRUISING YES NO

ARE THERE ANY OTHER PROBLEMS THAT ARE IMPORTANT TO YOU TODAY? SWOLLEN LYMPH GLANDS YES NO

NO YES ___________________________________________ SINUS ALLERGY SYMPTOMS YES NO

ALLERGIC-IMMUNOLOGIC
FREQUENT ILLNESSES YES NO
 HEALTH TEACHING
List down 5 health teachings pertaining to the following topics
listed below. Health Teaching should be part of your Video
Recording.

PREGNANCY BREASTFEEDING

NEWBORN BELIEFS AND MISCONCEPTIONS

This is to certify that the about information is true and correct based on the knowledge of my client.
Client’s information shall be treated with privacy and confidentiality.
FOR LEARNING PURPOSES ONLY

STUDENT NURSE
SIGNATURE
JOSELITO O. FILLE, RN, MAN

YEAR AND SECTION NCM 107 PROFESSOR