NURSING HEALTH HISTORY

I. BIOGRAPHICAL DATA
Name: Juan Miguel Garcia
Address: Sta. Rita, Pampanga
Birthdate: 09/16/2002 Age: 19 Occupation: N/A
Sex: Male Civil Status: Single Religion: Roman Catholic
Phone number: 09301943294
Provider of History: Px. Juan Miguel Garcia
Place of Birth: Porac, Pampanga
Language: Kapampangan, Tagalog, English
Educational Attainment: College Undergraduate
Chief Complain: Sore throat
Significant other/ Support Person: None
Admitting Diagnosis: Tonsillitis
Date of admission:
Date of Interview:

II. REASON/S FOR SEEKING HEALTH CARE

A. Reason for Seeking Health Care
The patient has been having a sore throat and swollen tonsils for about two days since
the day of the interview.

B. Feelings about seeking healthcare

The patient is feeling a bit nervous since he hasn’t seen any changes regarding
the pain.
III. HISTORY OF PRESENT HEALTH CONCERN
C - The patient stated that his throat feels swollen and is having a hard time talking.
O - It started two days ago with no seen changes.
L - The pain only stays on the patient's throat and doesn't radiate elsewhere.
D - He stated that the pain lasts all the time but is not painful. However, it makes the
patient uneasy and uncomfortable.
S - Mr. Garcia said that he rates the pain at 8, with 1 being the lowest and 10 being the
highest.
P - The patient also mentioned that the pain gets worse when he talks and swallows.
A - Mr. Garcia doesn't feel any other pain except for the one he mentioned. However, he
noticed that his breath smells awful since he had the symptoms.

Note: Use COLDSPA when appropriate

IV. PAST HEALTH HISTORY

A. Problems at birth
He recalls no problems at birth.

B. Childhood illnesses
The patient has no childhood illnesses.

C. Immunizations
The patient can no longer remember any immunizations at birth. However, the
patient took two doses of the Covid-19 Vaccine in the brand of Pfizer. He also
mentioned that he had his flu shot two weeks ago before the said interview.

D. Adult Illnesses
The patient recalls no adult illnesses.

NCMA 121 - HEALTH ASSESSMENT (RLE)

Nursing Health History (Format)
 E. Surgeries
The patient had a minor surgery on his head when he was 4 years old.

F. Obstetrical History
None.

G. Accidents
The patient fell off a running car when he was four-years-old which resulted to his
minor surgery on his head.

H. Prolonged pain
None.

I. Medications
He has not taken any medications.

J. Allergies
The patient stated that he had no allergies.
V. FAMILY HEALTH HISTORY
Mr. Garcia said that his family on his father's side has a history of hypertension
and diabetes. No hereditary illnesses from the mother's side.

VI. REVIEW OF SYSTEM

A. Skin, Hair, Nails:
- All are normal.

B. Head and Neck:

- Both are fine.

C. Eyes:
- No sign of poor eyesight.

D. Ears:
- Both auditory senses are working well.

E. Mouth, Throat, Nose, and Sinuses:

- All are normal except for the mouth and throat. Patient stated that he has been
feeling uncomfortable and experiencing bad breath in his mouth since he had the
symptoms. He also mentioned the pain in his throat.

F. Thorax and Lungs:

- Normal.

G. Breasts:
- Normal.

H. Heart and Neck Vessels:

- Normal.

I. Peripheral Vascular:
- Normal.

J. Abdomen:
- Normal.

K. Genitalia:

NCMA 121 - HEALTH ASSESSMENT (RLE)

Nursing Health History (Format)
 - Normal.

L. Anus/Rectum:
- Normal.

M. Musculoskeletal:
- Normal.

N. Neurologic:
- Normal.

VII. LIFESTYLE AND HEALTH PRACTICES

A. DESCRIPTION OF A TYPICAL DAY
The patient usually wakes up at 10 am and proceeds to eat his lunch. He then takes his
online classes until dinner. After that, he rests by playing mobile games and browsing
his social media accounts.

B. NUTRITION AND WEIGHT MANAGEMENT

The patient eats 3 to 4 times a day, with 4 being the maximum number, and only eats
regular serving.

C. ACTIVITY LEVEL AND EXERCISE

The patient jogs twice a week.

D. USE OF MEDICATION AND OTHER SUBSTANCES

Patient takes vitamin C every day. He also mentioned that he hasn't taken any
medications for his sore throat.

E. SLEEP AND REST PATTERN

The patient sleeps at 3 am and wakes up at 10 am, with no interruptions in between. He
also stated that he has no problem sleeping.

F. SUBSTANCE USE
The patient drinks alcohol occasionally. He doesn't smoke and use any illegal
substances.

F. SELF - CONCEPT AND SELF - CARE RESPONSIBILITIES

He takes care of himself by taking a bath, resting, and eating healthy foods
'sometimes'.

G. SOCIAL ACTIVITIES
He socializes with his friends by eating outside twice a week.

H. RELATIONSHIPS
The patient's relationship with his friends and family is good.

I. VALUES AND BELIEF SYSTEM

Mr. Garcia stated that he believes in God, prays every night, and attends online masses
every Sunday.

J. EDUCATION AND WORK

Juan Miguel Garcia is currently a first year nursing student at Our Lady of Fatima
University.

K. STRESS LEVEL AND COPING STYLES

He mentioned that he gets stressed with his studies and copes with it by resting, eating,
and playing mobile games.

L. ENVIRONMENTAL

NCMA 121 - HEALTH ASSESSMENT (RLE)

Nursing Health History (Format)
Lives nearby the market.

VIII. DEVELOPMENTAL LEVEL

The patient stated that at his age, he can already make adult decisions on his own. This
is based on Erikson's Psychosocial Stages of Development.

Note: Please refer to your laboratory manual about Collecting Subjective data: The
Interview and Health History which will serve as your guide to collect your data for
nursing health history. You should also use the table for your recording. (p7 – 12)

References:
Weber, J.R., Kelley, J.H, & Sprengel, A.D (2014). Lab Manual for Health Assessment in
Nursing (5th ed.). Wolter Kluwer Health/Lippincott Williams & Wilkins.

NCMA 121 - HEALTH ASSESSMENT (RLE)

Nursing Health History (Format)
NCMA 121 - HEALTH ASSESSMENT (RLE)
Nursing Health History (Format)