COMPREHENSIVE NURSING HEALTH HISTORY

Date: February 02, 2023

I. BIOGRAPHICAL DATA
a. Name: _MERRYL SHEENA BAQUEROS
b. Address: _BRGY. 62, TACLOBAN, CITY_
c. Age: 26_
d. Sex: _FEMALE__
e. Civil Status: __SINGLE__
f. Date of Birth: _APRIL 22, 1996___
g. Religion: __ROMAN CATHOLIC___
h. Occupation: _GOV’T EMPLOYEE__
i. Mother: _MERCEDES BAQUEROS_____
j. Father: __OILVER BAQUEROS______
k. Ordinal Position: ____4th _______
l. Type of Service: __SURGERY____
m. Source of Information: ___PRIMARY_______
n. Attending Physician: ___DR. SALINAS_

II. REASON FOR SEEKING CARE (CHIEF COMPLAINT): SEVERE ABDOMINAL PAIN

III. HISTORY OF PRESENT ILLNESS:

3 months PTA patient started experiencing abdominal pain that is tolerable and did not seek
for medical advice, after 2 months the patient experienced a severe epigastric pain radiating
to the back and to the spine with a pain scale of 8/10, associated with fever and vomiting.
She did not take any pain reliver and directly sought for consultation at Divine Word
Hospital and advised for whole abdominal ultrasound and showed results of gallstones.
Resistance of the above symptoms prompted the patient to sought consult at EVMC OPD
and referred to ER for admission.

IV. PAST HEALTH HISTORY:

a. Childhood and Infectious Disease: No reported childhood illness
b. Immunization: Fully immunized
c. Allergies: No known allergies
d. Medications taken: None
e. Major Surgeries and Hospitalization: No major injuries and hospitalizations undergone.
f. Injuries: No injuries experienced
g.
V. FAMILY HISTORY:
Mother- Hypertensive
Father- Diabetic, underdone cholecystectomy 6 months ago.

VI. PSYCHOLOGICAL HISTORY AND LIFESTYLE:

a. Alcohol Use: N/A
b. Drug Abuse:N/A
c. Tobacco Use: N/A
d. Domestic and Intimate Partner Violence: N/A
e. Sexual Practice: N/A
f. Alcohol Use: N/A
g. Drug Use: N/A
h. Tobacco Use: N/A
i. Domestic and Intimate Partner Violence: N/A 
j. Travel History: No recent travel. No history of travelling outside the country
k. Work Environment: Government office
l. Home Environment: Family structure is composed of the father, mother and his siblings.
The type of house is a bungalow type of house. The roof is composed of galvanized iron
sheets, wall is made of cement. 
m. Hobbies and Leisure Activities: Watching Korean drama
n. Stress: Being hospitalized
o. Education: College graduate
p. Economic Status: Middle class
q. Ethnic Background: Waray-Waray