ILOILO DOCTORS’ COLLEGE

College of Nursing
West Ave., Molo,Iloilo City

NAME OF STUDENT: ____________________________________________________________

YR. & SEC.:____________________________________
AREA ASSIGNED:________________________________________________________________
DATE & TIME OF EXPOSURE:_________________________________________________
CLINICAL INSTRUCTOR: __________________________________________________________

HEALTH HISTORY ASSESSMENT TOOL

I: VITAL INFORMATION

Client’s Name (initials only): _____________________________________________________

Age: ________ Sex: ________ Civil Status: _______ Religion: __________________________
Nationality: _________________ Birth Date: ___________ Birthplace: ___________________
Current Address: ______________________________________________________________
Educational Attainment: ________________________________________________________
Occupation: __________________________________________________________________
Source of information: _________________________________________________________

Mental & Emotional Status: (pls check)

Is the client:
______ alert ______cooperative ______anxious ______ disoriented
______ oriented ______understanding ______restless ______ uncooperative
______focus ______coherent ______confuse ______ others

Vital Signs, Height & Weight

Temp. __________BP _________ RR _______ PR _______ Height:________ Weight________
Does the patient experience any pain? _________ if yes, ask the following:
What part of the body/location? ______________________
Description of Pain by the client: __________________________________________________
When did it occur? _____________________________________________________________
For how long did the client experienced pain? ________________________________________
What is the pain scale from 0-10? ____________________
What are other associated signs & symptoms the client experienced? ____________________

What are other signs & symptoms associated with pain? ________________________________

II HISTORY OF PRESENT ILLNESS

1. Any illness experienced now? (specify)______________________________________
2. When did it occur? ______________________________________________________
3. What are the associated factors of illness? ___________________________________

4. What is the cause/triggering factor of the present illness? _______________________

______________________________________________________________________
5. Any medication/s taken? _________________________________________________
6. Any alternative medicine/remedies applied/used? Yes _____ No ______
Specify: ______________________________________________________________

III PAST HEALTH HISTORY

1. Does the patient have allergy/allergies? _______ yes ______ no
2. What are the allergies? (pls specify) Food _____________________________________
Drug/s ________________________________Others: ___________________________
3. Any accidents and injuries experienced? (Specify) _______________________________
4. Any surgical operation experienced?(Specify) __________________________________
5. Any hospitalizations? (state the year/date & diagnosis) __________________________
__________________________________ Any blood transfusion? _________________
6. Any medications taken during hospitalization? _________________________________
_______________________________________________________________________
7. Immunizations received ___________________________________________________
 8. Any childhood diseases experienced? Pls. check
______ measles ______ mumps ______ chicken pox ______ German measles
Others☹specify) _______________________________________________________
9. Any other illnesses experienced?
______ dengue _____ typhoid fever _______ diarrhea _______ flu
______ hypertension _______ diabetes _______ asthma _______ arthritis
______urinary tract infections ______ cancer _____ visual problems _______ TB
______ heart problems ______ kidney problems _________ respiratory problems
Others: _______________________________________________________________

IV FAMILY HEALTH HISTORY

1. What are the hereditary diseases?
________ Heart problems
Specify: _____________________
________ Allergies
Specify: _____________________
________ Respiratory problems
Specify: _____________________
________ Skin problems
Specify: _____________________
________diabetes
Specify: _____________________
__________ kidney problems
Specify: ________________________
__________ cancer
Specify: ________________________
__________ arthritis
Specify: _________________________
__________neuro/mental health problems
Specify: _________________________
__________ hypertension
Specify: _________________________

2. Does the patient have disability or handicap? (specify) ________________________

3. What is the usual cause of death among family members? _____________________

V LIFESTYLE OR CURRENT HEALTH STATUS

1. What are the client’s routinely activities or activities of daily living?______________

____________________________________________________________________
2. Any difficulties or discomforts felt with the following activities? Pls. check
_____ eating _____ bathing _____ grooming/combing hair
_____ walking _____ toileting _____ driving
_____ playing/sports ______ climbing the stairs ______ reaching out cabinets
_____ reading _____ prolonged sitting/standing ______ housekeeping
_____ laundry _____ gardening _____ lifting/pushing/carrying things
_____ shopping/malling______ exercising _____cooking

3. Anyone in the family that smoke? _________________________________________

How often? ____________ How many sticks/packs per day? ___________________

4. Anyone in the family that drink alcoholic drinks/hard drinks? ___________________

How often? ____________ How much is the amount taken?___________________
5. Does the family have leisure activities? (Specify)_____________________________
6. What are the leisure activities does the patient engaged in? __________________
___________________________________________________________________
How often? ________________________ with whom? ______________________
7. Sleeping patterns: What is the client’s sleeping time? _______________________
Position: _____________________ How many hours/day? ___________________
Waking time: ___________ Nap time: __________ No. of pillows used: ________
8. Dietary Pattern: How many meals/day? ___________ snacks/day ____________
Type of food taken: __________________________________________________
__________________________________________________________________
Water intake/day: ___________________ Any dentures? ___________________
9. Elimination pattern: How often does client move bowels? ___________________
Is there any difficulty? ___________ if yes , why? __________________________
__________________________________________________________________
10. Any vices practiced? _______ If yes, specify: ______________________________
Year started: ______________________

VI OBSTETRICAL & GYNECOLOGICAL HISTORY/REPRODUCTIVE HEALTH HISTORY:

IF MALE:
1. Any illness experienced regarding reproductive system? ______ Specify_______________
2. At what age was the patient circumcised? _______________________________________
Where: ? _____ BHS _____ RHU _____ Private Clinic
_____ Home _____ School Clinic _____Hospital
Others: _________________________________________________
 Who performed? ______ Rural Health Physician _______ Private Doctor
______ Hospital Surgeon _______ Herbolario
Others: _____________________________________________
3. When did puberty started? __________________________________
4. Any reproductive problem presently experienced? __________________________
5. Any hereditary illness on reproductive health? _____________________________
6. Did the patient had a check-up on reproductive health? _____________________

IF FEMALE:
1. When was the first menstruation (menarche)? _________________________________
2. Menstrual cycle: ____ 28-30 days ____ less then 28 days ____ more than 30 days
3. How many days? _____ 1 day _____ 3-5 days ____ more than 5 days
4. How many pads consumed/day: ____ 3-8 pads ____ 7-10 pads ____ 11-15 pads
5. Any discomforts felt before, during & after menstrual period? _______
If yes, specify or describe:______________________________________________________
Medications/comfort measures done during dysmenorrhea:__________________________
___________________________________________________________________________
6. Any reproductive problem experienced? __________________________________________
7. Any hereditary illness on reproductive health?______________________________________
8. Does the client had a check-up regarding reproductive health? ________________________
9. No. of pregnancies: __________________________________________________________
Type of delivery: ____________ Normal ______________ CS surgery
Where: _____ Home _____ RHU ______ BHS _____ Private clinic _____ Hospital
_____ Lying In Facility
By whom: _______ Hilot ______ Midwife _______ Nurse _______Doctor
10. Had pre-natal check-up? _______ Where? _______________________________________
11. Any difficulty of labor & delivery experienced? _____ Yes _____ None
12. Does/did the patient practice family planning? ______ Method: _______________________
13. Is the client experiencing symptoms of menopausal? _______ Specify: _________________
14. Is the cliient on menopausal period? ________________

VII PERSONAL & SOCIAL HISTORY

1. What is the occupation? ___________________ Workplace: __________________________
Any occupational hazards? ______________________________________________________
2. What is the educational attainment? ______________________________________________
3. Where does the client live? _____ rural _____ urban _____ subdivision/suburbs
4. How does illness affects the relationship & daily activities of the family? __________________
_____________________________________________________________________________
5. What is the estimated income of the client? _______ below 5K/mo. _______ above 5K/mo.
Other source of income? ________________________________________________________
6. Is the patient sexually active? ______
7. Any religious values, beliefs practicesd? ____________________________________________
8. What is the outlook in life of the client ? ____________________________________________

VIII STRESSORS
1. Physical or physiological stressors: _______________________________________________
2. Psychological stressors: ________________________________________________________
3. Other stressors: ______________________________________________________________

Documented by:

____________________________________
Student Signature

C.I.’S Remarks:
_____________________________________________________________________________________

_____________________________________________________________________________________

Noted & Corrected by:

____________________________________
C.I. Signature

Date: _____________________________

Chn/ncm 104 RLE/mcrga 2020