I.

Demographic

Name:

Age: Birthday: Gender:

Birthplace:

Address:

Nationality: Religion:

Occupation: Highest Educational Attainment:

Mother: Age:

Father: Age:

Diagnosis:

Hospital No.:

II. Chief Complaint

Why?
III. Present Health History
Reason?
How long? Pain? Character? Radiating?
Location?

Self-Medication?
Consultation? Referrals? Conscious?
When? Why? State?
Where?
Assessments?
Labs?
Prescription?
IV. Past Health History
__Vaccine?
__HepaB __IPV
__DTaP __Pneumonia
__PentaHib __Oral Polio
Injuries? Chickenpox? Pregnancy?
Age? Age? How many?
Why? Why? When?
Past Admission? Medication? Cancer?
Why? Chronic Disease? When?
Age? Age?
How long? When?
Allergies?
V. Family Health History
Familial Disease?

VI. Gordons
1, Health Management
Before?
How?
Herbal? Maintenance?
Vitamins? Hilot? Albularyo?
Health Perception
Healthy? Why?
During?
How?
Herbal? Maintenance?
Vitamins? Hilot? Albularyo?
Health Perception
Healthy? Why?

2. Nutrition-Metabolic (B and D)
Food Allergies? Favorite foods?
Picky? Hate foods?
Water? Beverages?
Input?
Sept. 03 Sept. 04 Sept. 05
3. Activity and Exercise (B and D)
Hobby? Exercise?
Altered? Changes?
Before Hospitalization During Hospitalization

4. Elimination Pattern (B and D)

Urination? Color?
Pain? Quantity?
Odor? Difficulty?
Feces? Color?
Frequency? Odor?
Difficulty? Pain?

5. Cognitive-Perception
Forgetful? Vision?
Schooling? Honor?
Jean Piaget? Felt?

6. Sleep and Rest (B and D)

HS? Difficulty in Sleeping?
Afternoon Nap? Length?
 Disturbance? Snore?
Reason? Loud? Character?
Sleep Talking? Walking? What make him/her sleepy?

7. Role-Relationship Pattern
Roel in family? Married/Single?
Relationship with the family? Siblings? Father? Mother?
Friends?
Role in School? Work? Barangay?
Disturbance?
Changes?

8. Sexuality and Reproduction

Menarche? Menopause? Circumcision?
Satisfaction? Psychosexual? Infertile?
Pregnancy? Children?

9. Coping Stress Tolerance (B and D)

Angry? Calm?
Dealt?

10. Self-Perception and Self-Concept (B and D)

Body Image?
Think of Self? Beautiful? Ugly? Happy? Sad? Depress?

11. Value and Belief (B and D)

Pray? Family?
Religion?
Church? When? How often?
Knows Right and Wrong?
Beliefs in magical creatures? Santa Claus?

VII. PA
GCS: PR: O2Sat: HR: RR: Temp:
Weight: Height: BMI: