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I.

PATIENT DEMOGRAPHIC PROFILE

Name: ___________________________ Age/Gender: _____________ Status:


________________
Home Address: _____________________________________________________________________
_____________________________________________________________________
Religion: __________________ Nationality: ________________ Occupation:
__________________

II. HEALTH HISTORY PROFILE


A. Past Medical History

1. Pediatric and Adult Illness

Date Illness Medication Remarks

2. Immunization

Immunization Doses Dates Remarks

3. Hospitalization

Date/Year Hospital Diagnosis Duration

4. Injuries and Accidents

5. Transfusions

6. Allergies (specify)

B. Family History

C. Social and Personal History


1. Occupation
2. Number of Children
3. Military experience, foreign travel
4. Habits
5. Diet
6. Type of Family
7. Cultural and Religious Beliefs
8. Brief description of an average day
D. Review of System (for the past 6 months). Physical Assessment

General Weight loss Fatigue Anorexia


Night Sweats
Chills Fever Weakness

Skin Itch Rash Lesions


Bruising
Bleeding Color change

Eyes Pain Discharge Itch Vision loss


Diplopia
Excessive tearing Glasses/contact lens Date
of last exam

Ears Earaches Discharges Tinnitus


Hearing Loss

Nose Obstruction Discharges Epistaxis

Throat and Sore throats Bleeding gums Toothache


Mouth Dentures

Neck and Swelling Dysphagia


Head Hoarseness

Chest Cough Sputum:Amount and Character


Hemoptysis
Wheeze Pain on respiration Dyspnea

Cardiovascula Precordial pain Palpitation Dyspnea


r on Exertion
Paroxysmal nocturnal Dyspnea
Orthopnea
Edema Heart murmur Thrombophlebitis
Claudication

Gastrointestin Heartburn Nausea Vomiting


al Bloating
Diarrhea Food Intolerance Excessive gas
or indication
Constipation Changes in Bowel Movement
Jaundice Melena Hemmorhoids
Hernia

Genitourinary Heartburn Nausea Vomiting


Bloating
Diarrhea Food Intolerance Excessive gas
or indication
Constipation Changes in Bowel Movement
Jaundice Melena Hemmorhoids
Hernia

Extremities Joint pains Varicose veins


Claudication
Back pain Edema Stiffness
Deformities

Endocrine Hot flashes Hair loss


Temperature Intolerance
Polydipsia Goiter

Neurology Numbness Tingling Tremor


Fainting
Headaches Muscle weakness Ataxia
Unconsciousness Paralysis/paresis Memory
loss
Dizziness Seizure

Psych Anxiety Depression Sexual Problems


Insomnia
Nigthmares

Others

III. CURRENT HEALTH PROFILE

A. Presenting complaints and medical diagnosis to include intervention done


prior to hospitalization

B. Application of the Nursing Process

1. Assessment Findings (Head to Toe)

Laboratory/Diagnostic Results

Date Lab Exam Patients Normal Interpretation/Signific


Results Findings ance