ARMY COLLEGE OF NURSING JALANDHAR CANTT

FUNDAMENTAL OF NURSING

FORMAT FOR HISTORY TAKING

Patients Identification Data:

Name
Age
Sex
Marital Status
Hospital Registration No.
Ward/Bed No.
Address & Contact No:
Date of Admission
Date of Discharge
Diagnosis (Provisional)
Diagnosis (Final)
Name of Operation
Date of operation
Name of the Doctor
Religion
Education
Occupation (usual and present)
Monthly Family Income (Rs)

Nursing Alert:
Sensitivity / Allergy / Precaution
Weight: ----------
Height: ----------
Chief complaints with duration: “Reason For Hospitalization”: Examples of chief
complaints:
Chest pain for 3 days.
Swollen ankles for 2 weeks.
Fever and headache for 24 hours.
 Pap smear needed.
Physical examination needed for complaint

History of present Illness: Gathering information relevant to the chief complaint, and the client's
problem, including essential and relevant data, and self medical treatment

Elements for present illness:

 Location. What is the site of the problem? ...
 Quality. What is the nature of the pain? ...
 Severity. ...
 Duration. ...
 Timing. ...
 Context. ...
 Modifying factors. ...
 Associated signs and symptoms.

Present Medical History: DM, TB, HIV, Communicable disease, and Jaundice, Typhoid,
Hepatitis, and Arthritis, Cardiac disease, Respiratory disease, CNS, Renal disease... etc. included in the
medical history.

Present Surgical History: included Road side Accident, Amputation, Burn, Fracture, Crushed
injury, Blood transfusion, any surgery etc.

History of past Illness: Illness/ Medications / Any restrictions. The purpose: (to identify all major
past health problems of the client)
This includes:
Childhood illness e.g. history of rheumatic fever.
History of accidents and disabling injuries
History of immunizations and allergies.
Physical examinations and diagnostic tests.

Past medical history ... In a medical encounter, a past medical history is the total sum of a
patient's health status prior to the presenting problem.
 Past Surgical History: History of hospitalization (time of admission, date, admitting
complaint, discharge diagnosis and follow up care.

History of operations "how and why this done"

Menstrual History:
Age of Menarche:
Premenstrual sign:
Last day of menstruation:
Cycle:
Number of days:
Associated sign:

Obstetrical History: GPLA

Family History: Having a chronic disease in your family history doesn't guarantee your risk of
developing the same disease. Chronic diseases such as heart disease, diabetes and cancer are caused by
a combination of factors that include genes, behavior, lifestyle and environment. ... Recording your
family health history is simple.
Family history of communicable diseases.
Heredity factors associated with causes of some diseases.
Strong family history of certain problems.
Health of family members "maternal, parents, siblings, aunts, uncles…etc.".
Cause of death of the family members "immediate and extended family".
Family Tree:

Keys:

Male

Pt. Female

Marital

Patient

Pt.

Family Composition:

S.no Name of Age Sex Education occupation Marital Relationship Health

Family with Patient Status
Member

 Write in brief about Family history:

Environmental History: "to gather information about surroundings of the client", including
physical, psychological, social environment, and presence of hazards, pollutants and safety measures."
Health facility near home:
Type:
1. Hospital
2. Health Centre
3. Any other : if any other (specify )
Distance: ------------- kms.
Transportation facility: Yes/No
Type: Kuchcha/ Pucca
No. of Rooms:
Toilet: Indian /western/Temporary/Open

Electricity: Yes/No

Drinking water source

Tap/Well/Pond/River /Hand /pump

Personal Habits
Allergies: environmental, ingestion, drug, other.
Habits "alcohol, tobacco, drug, caffeine"
Medications taken regularly "by doctor or self prescription
Nutritional pattern:
Exercise patterns.
Sleep patterns (daily routine).
The pattern life (sedentary or active)
Elimination patterns

Conclusion:

Physical Examination
General appearance:
Body built: proportionate, varies with lifestyle, excessively thin or obese
Gender & Race:
Facial Expression: no distress noted, frowning, depressed, and worried
Posture & Gait: relaxed, erect posture, coordinated movement, tense, slouched,
and bent posture, uncoordinated movement, tremors, unbalanced gait.
Nourishment: Nourished, malnourished, over nourished
Health: good and fair
Affect/Mood: appropriate to situation, inappropriate to situation, sudden mood
change, paranoia
Activity: active, Inactive/dull
Speech : understandable., moderate pace, clear tone ,and inflection rapid or slow
pace, overly loud or soft
Hygiene and grooming : clean, neat, dirty and unkempt

Height:

Weight:

Vital Signs: Temperature: Pulse: Respiration: B. P.

Mental Status: Counscious (oriented to time, place and person), semiconscious, unconscious, coma,
vegetative state

Head: Scalp:
Hair:
Integuimentary system
Face:
Sinus:
Nodes:

Eyes: Occular Movement:

Pupils:
Sclera:
 Cornea:
Eye Lid:
Conjunctiva:
Disease condition:
Eye Sight:

Ears: External structures

Symmetry:
Hearing:
Any Discharge:
Disease condition:

Nose: External structure

Septum:
Mucous Membrane:
Patency
Olfactory Sense:

Mouth: Buccal mucosa:

Gums:
Teeth:
Palates and Uvula
Tonsillar area
Voice breath

Neck: Muscles:
Trachea:
Thyroid:
Nodes:
Vein distension:

Thorax: Chest shape:

Respiratory Rate:
 Type of Respiration:
Thoracic Expansion:
Palpation:
Percussion:
Breath sounds:
Breast: Inspection:
Palpation:
Lymph Node:

Cardiovascular system: Precordium: Inspection

Palpation
Auscultation
Apical rate and Rhythm

Central and Peripheral Vessels: Carotid arteries:

Peripheral pulses: brachial
Radial:
Femoral:
Popliteal:
Dorsal Pedal:
Post. Tibial:
Capillary Refill:
Abdomen: Inspection:
Auscultation:
Percussion:
Palpation:

Musculoskeletal system: Gait:

Upper Extremities:
Lower extremities:
Muscle strength:
Joints:
Range of Motion:
Spine:
Nervous system: Mental status:
Language
Orientation
Memory Attention span
Level of Consciousness (GCS)
Cranial Nerves
Deep Tendon Reflexes
Gross and Fine motor function of UE and LE
Sensory function:
Light touch
Pain
Temperature
Position

Perineal examination: Inspection

Palpation

 Diagnostic Evaluation:

D Date Investigation done Normal value Patient value Inferences

 MEDICATION

s. Drug Pharmacological Dose Frequency Route Action Side Nursing

No Trade Name Effect responsibility
Name

 NURSING CARE PLAN

Nursing Nursing Goals Nursing Rational Nursing Evaluation

Assessment Diagnosis Intervention Implementation
 Subjective
Data
Objective
Data

 NURSES NOTES

Date / Time Medication Diet / Nutrition Observation, Signature

Intervention and
Evalution

 HEALTH EDUCATION ON DISCHARGE

 BIBLIOGRAPHY