Professional Documents
Culture Documents
GENERAL INFORMATION
Name: ________________________________________________
Age: _______
Birthdate: _____________________
Address: ______________________________________________
Admission: Date:_____ Time: _________
From: Home: _________________________________________
Hospital: _______________________________________
Others: ________________________________________
HEALTH HISTORY
Reason for this visit (chief complaint):
_______________________________________________________
History of Present Illness:
_____________________________________________________________________________________________
_________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________
History of Past Surgeries/ Hospitalizations:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________
Diagnoses/ Impressions:
_____________________________________________________________________________________________
_________________
Source of Information: ___________________________________ Date:___________________
ACTIVITY/ REST
Subjective (Reports)
Occupation:____________________________________________
Able to participate in usual activities/ hobbies:
_____________________________________________________________________________________________
_________________
Leisure time/ diversional activities:
_____________________________________________________________________________________________
_________________
Ambulatory:_____________
Gait (describe):__________________________________________
_____________________________________________________________________________________________
_________________
Activity level (sedentary to very active):
_______________________________________________________
Daily exercise (type): ____________________________________
Muscle mass/ tone/ strength (e.g normal, increased, decreased):
_______________________________________________________
_______________________________________________________
History of problems/ limitations imposed by condition (e.g. immobility, cant transfer,
weakness, breathlessness): _______________________________________________________
_____________________________________________________________________________________________
_________________
Feelings (e.g. exhaustion, restlessness, cant concentrate dissatisfaction):
________________________________________
_______________________________________________________
Sleep: Hours ___________________ Naps: _________________
Insomnia:________________ Type: _________________
Rested on awakening: ________
Excessive grogginess: _________
Bedtime rituals: _________________________________________
Relaxation techniques: ___________________________________
Sleeps on more than one pillow: ___________________________
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Immediately
after
After 5
minutes
Strength:
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Alert: _______
Drowsy: ________
Lethargic: ______________
Stuporous: ______ Comatose: ____Cooperative: _____________
Combative: ___________
Agitated/ restless: _____________
Follows commands: ____________
Delusions (describe): ____________________________________
_______________________________________________________
Hallucinations (describe): _________________________________
_______________________________________________________
Affect (describe): ________________________________________
Speech: _______________________________________________
Memory
Recent: ______________________________________________
Remote: _____________________________________________
Glasgow Coma Scale: ___________________________________
Test
Score
EYE OPENING RESPONSE
SCORE
Spontaneously
4
To speech
3
To pain
2
None
1
MOTOR RESPONSE
Obeys
Localizes
Withdraws
Abnormal flexion
Abnormal extension
None
VERBAL RESPONSE
Oriented
Confused
Inappropriate words
Incomprehensible
None
TOTAL SCORE
6
5
4
3
2
1
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5
4
3
2
1
15
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Instructions
Scoring
Date
"Tell me the date?" Ask for
Orientation omitted items
Place
"Where are you?" Ask for
Orientation omitted items.
Register 3
Objects
Serial
Sevens
Recall 3
Objects
Naming
Writing
Drawing
Scoring
30
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_______________________________________________________
SAFETY
Subjective (Reports)
Allergies/ sensitivity (medications, foods, environment, latex):
_____________________________________________________________________________________________
_________________
_______________________________________________________
Type of reaction: ________________________________________
_______________________________________________________
Exposure to infectious diseases (e.g. measles, influenza, pink eye):
__________________________________________________
_____________________________________________________
Exposure to pollution, toxins, poisons/ pesticides, radiation
(describe reactions):
____________________________________
_____________________________________________________________________________________________
_________________
Living conditions (with whom/ location of residence):
_______________________________________________________
_______________________________________________________
_______________________________________________________
Travelled Places: ________________________________________
_______________________________________________________
_______________________________________________________
Immunization history: (no. of doses)
BCG: ______ OPV:_______ Booster: ______
DPT: _________ Booster: _________
Hepatitis:________ Booster: ______________
Others (specify): ______________________________________
Altered/ suppressed immune system (list cause):
_____________________________________________________________________________________________
_________________
_______________________________________________________
History of STD (date/ type): ______________________________
_______________________________________________________
test: __________________________________________________
High risk behaviours: ____________________________________
_______________________________________________________
Blood transfusion/ number: ___________ Type: _____________
Date: ______________________________
Reaction (describe): ___________________________________
_____________________________________________________
Use seat belt regularly: ____Bike helmets: ______
Other safety devices: ____________________________________
Work place safety/ health issues (describe):
_______________________________________________________
Currently working: ______
Rate working conditions (e.g. safety, noise, heating, water, ventilation):
____________________________________________
_______________________________________________________
History of accidental injuries: _______________________________
_______________________________________________________
Skin problems (e.g. rashes, lesions, moles, breast lumps, enlarged nodes) describe:
_____________________________________________________________________________________________
_________________
_______________________________________________________
Delayed healing (describe):
_____________________________________________________________________________________________
_________________
_______________________________________________________
Cognitive limitations (e.g. disorientation, confusion):
_______________________________________________________
Sensory limitations (e.g. impaired vision/ hearing, detecting hot/cold, taste. Smell,
touch):_______________________________________
_______________________________________________________
Prostheses: _______Ambulatory devices: _____________________
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_______________________________________________________
Violence (episodes/ tendencies): ____________________________
_______________________________________________________
Objective (Exhibits)
Body temperature:__________
Skin integrity (e.g. scars, rashes, ulcerations, ulcerations, bruises, blisters, burns degree/
%, drainage) / mark location on diagram:
_______________________________________________________
(Front)
(Back)
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RR= ________
Labor
1.Abdominal Status: FU: _____ EFW: ________ AOG: _________
a) Presence of uterine contraction:
frequency
duration
interval
intensity
b) IE Result:
ti
m
e
Dilat
n
Effac
et
BO
W
Con
d.
stati
on
discharg
es
Done By
Yr
Meth
od of
Del.
Place of
del./attende
d by
Birt
h
wt
Cond
n
Condn
of baby
Prenatal History
d1) General physical and emotional
state of the mother during
pregnancy
________________________________________
__________________________________________________
d2) Prenatal check up/consultations:
1st trimester (frequency):___________________________
Diagnostic & result: _____________________________
2nd trimester: _____________________________________
Diagnostic & result: _____________________________
3rd trimester: _____________________________________
Diagnostic & result: _____________________________
d3) Pregnancy complications & discomforts during present
pregnancy(if any)- nausea and vomiting: _______________
loss of appetite: ______ edema: ________ UTI : ________
co morbid illness: ______ Vagl bleeding: ____________
abnormal weight change: ______ HPN: _______
d4) Was pregnancy planned: Yes: ______ No: ______
when was quickening felt: __________________________
attitude of father: __________________________________
place where mother plans to give birth: _______________
_________________________________________________ Gynecologic History:
a.) Surgery affecting the: breast: _____ Mastectomy: _______ hysterectomy: _____
Hysterectomy: ______ TAHBSO :
b.) Ectopic pregnancy: _______
c.) Reproductive tract diseases: PID: ______
Polycystic ovarian disease: ______ H-mole : _____
Others: specify: __________________________________ d.)Breast:(symmetrical): ______ size
and shape ______ retractions/ dimpling: ______ nipple discharge: _______ redness of the
skin: _____ visible superficial veins_____ lumps or masses on both breasts: _______
axillary lymph node mass: _____ tenderness: __________
d.) Abdomen: (minimal) gravidarum striae: _______
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