General Santos Doctors’ Medical School Foundation Inc.

Bulaong Subdivision, Barangay West, General Santos City 9500

Tel No.: (083) 302-3507, Telefax No.: (083) 552-9793

BULALAQUE, CHARISSE D. BSN3C

NCM117LEC March 23, 2022
HISTORY TAKING
I. Biographical Data

Question Rationale

What is your full name?
The response will offer baseline data on
the client's memory and speaking abilities.
It will also check preventative measures
against human mistake and if we are
delivering the correct order and medicine
to the correct client.

When were you born? The client's response will assist us in

determining his or her memory condition.
To identify and eliminate drug and
treatment delivery errors, two-factor
identification (name and birthday) is
utilized.

Do you have any food allergies or
medication allergies?
The response of the client will be our
baseline for determining what diet and
medication can we give to provide proper
nutrition and regimen without resulting to
any harmful reactions.

II. History of Present Health Concern

Question Rationale
How long has it been going on? The response of the client will indicate how
long has he or she been suffering from the
condition. To determine the severity of the
condition.
 What makes it worse ? The response of the client will be able to
help us identify what event or scenario
mostly triggers the condition.
What helps it? The client’s response will assist us to know
what management should be given to
various client depending on their response.

III. Past Health History

Question Rationale
Do you have any childhood illnesses? The response of the client will be able to
maintain good health, parents should be
aware of the signs of common childhood
diseases and how to treat them before they
proceed to a more serious stage. For
particular guidance on common kid ailments,
always visit a health care practitioner.
History of any other surgeries and Client’s response to question will determine
trauma? if he or she had undergone to any surgery
that may intervene the interventions and the
degree of its trauma.
Are you taking any current medication? The response of the px regarding Medication
histories is important reducing prescription
mistakes and the hazards they pose to
patients. Aside from reducing prescription
mistakes, thorough medication histories can
help detect drug-related pathology or
changes in clinical symptoms that may be
caused by drug therapy.
IV. Family History

Question Rationale
Does your family have history of mental Knowing that these illnesses run in family
might help you take charge of the mental
condition?
health and seek expert care. The client
response will help the medical provider to
lessen the risk of it.
Does anyone in our family have any The response of the client in having chronic
other serious illnesses, such as cancer, illnesses, mental disorder, and genetic birth
stroke, Alzheimer's/dementia, genetic disorder will help us identify if the client may
birth disorder, or osteoporosis?
have any underlying conditions that may be
one of the contributing factors in the his/her
mental condition.
Does your family talks about how mental The client’s response to this question will be
health matters? able to help us classify if they give
importance about mental health.

V. Developmental Stage

Question Rationale
How did the trauma impact yourKnowing the response of the client will aid us
relationships with others? to correlate his or her current condition in
establishing relationship with others.
Were there any physical health effectsKnowing if there is any physical
from the trauma? manifestation of the trauma that the client is
experiencing will help us to give what proper
treatment according to its manifestation
should be given.
How did the trauma impact yourThe client’s response will determine how
relationships with others? trauma deeply impacted his or her
relationship with others to rethink of how to
create or regain relationships.
VI. Spiritual Beliefs

Question Rationale
Are you affiliated with a religious orKnowing what religious or spiritual
spiritual community? community our client was affiliated will be
able to open our way in restoring their
distorted faith towards their religion.
Do you see yourself as a religious or Getting answer from this question will help
spiritual person? If so, in what way? us to know how deep the connection our
client has with the creator.

Has your religion or spirituality been Knowing the involvement of the religion of the
involved in the way you have coped client will aid us to lessen the risk of
with this event? If so, in what way? behavioral risks through religious lifestyles.