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    Complete Health History: Patient Profile

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    Carissa Mae Tapec Estrada
    This document contains a complete health history form for a client interview. It collects biographical data, chief complaints, past medical history, current medications, previous hospitalizations, communicable diseases, social history, family medical history, review of systems, and vital signs. The purpose is to comprehensively document the client's health status and relevant factors.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Complete Health History: Patient Profile

    Uploaded by

    Carissa Mae Tapec Estrada
    34 views3 pages
    This document contains a complete health history form for a client interview. It collects biographical data, chief complaints, past medical history, current medications, previous hospitalizations, communicable diseases, social history, family medical history, review of systems, and vital signs. The purpose is to comprehensively document the client's health status and relevant factors.

    Original Title

    Health History

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    This document contains a complete health history form for a client interview. It collects biographical data, chief complaints, past medical history, current medications, previous hospitalizations, communicable diseases, social history, family medical history, review of systems, and vital signs. The purpose is to comprehensively document the client's health status and relevant factors.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    34 views3 pages

    Complete Health History: Patient Profile

    Uploaded by

    Carissa Mae Tapec Estrada
    This document contains a complete health history form for a client interview. It collects biographical data, chief complaints, past medical history, current medications, previous hospitalizations, communicable diseases, social history, family medical history, review of systems, and vital signs. The purpose is to comprehensively document the client's health status and relevant factors.

    Copyright:

    © All Rights Reserved
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    UNIVERSITY OF PANGASINAN

    PHINMA EDUCATION NETWORK


    COLLEGE OF NURSING

    COMPLETE HEALTH HISTORY

    INTERVIEWER: ____________________________________ DATE: ____________________

    BIOGRAPHICAL DATA
    CLIENT NAME: _______________________________________________________________
    ADDRESS: ___________________________________________________________________
    PHONE/ MOBILE NUMBER: ______________________________________________________
    DATE OF BIRTH: ______________________________________________________________
    BIRTHPLACE: _________________________________________________________________
    OCCUPATION: ________________________________________________________________
    USUAL SOURCE OF HEALTH CARE: _________________________________________________
    EMERGENCY CONTACT: _________________________________________________________
    PATIENT PROFILE
    AGE: _______
    GENDER: __________________
    NATIONALITY: ___________________
    MARITAL STATUS: _________________

    CHIEF COMPLAINT (HISTORY OF PRESENT ILLNESS):


    __________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________

    PAST HEALTH HISTORY


    _____________________________________________________________________________
    _____________________________________________________________________________

    MEDICAL HISTORY
    ALLERGIES:
    ___ DRUG: ____________________________
    ___FOOD: ____________________________
    ___ENVIRONMENTAL: __________________________
    ___BLOOD REACTION: __________________________
    ___OTHERS: __________________________________

    CURRENT MEDICATIONS: (PRESCRIPTION & OTC)


    DRUG & DOSE FREQUENCY LAST DOSE
    _________________ ___________ ___________
    _________________ ___________ ___________
    _________________ ___________ ___________
    _________________ ___________ ___________

    PREVIOUS HOSPITALIZATION: (ILLNESS, ACCIDENTS, INJURIES, BLOOD TRANSFUSION)


    HOSPITALIZATIONS: ________________________________________________________________
    OPERATIONS: _____________________________________________________________________
    DATE: _________________________________________
    COMMUNICABLE DISEASES/ CHRONIC/ SERIOUS ILLNESS: _____________________________________
    CHILDHOOD ILLNESS: ________________________________________________________
    IMMUNIZATIIONS/ DATE: _____________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________
    FAMILY HEALTH HISTORY

    YES NO YES NO
    ARTHRITIS HYPERTENSION
    BLOOD PROBLEM (ANEMIA, KIDNEY PROBLEM
    BLEEDING) LIVER PROBLEM
    CANCER LUNG PROBLEM (ASTHMA,
    DIABETES MELLITUS BRONCHITIS, PNEUMONIA, TB,
    EYE PROBLEM (CATARACTS, SOB)
    GLAUCOMA) STROKE
    HEART DISEASE (MI, HEART THYROID PROBLEM
    FAILURE) ULCER
    GERD PSYCHOLOGICAL DISORDER
    HIV/ AIDS

    OBSTETRIC HISTORY (FEMALES)


    LMP: ___________________________
    GRAVIDA: _____ PARA: _____TERM: ______ PRETERM: _____ ABORTION: ______ LIVING: ______
    MENOPAUSE: _____YES ____ NO
    SOCIAL HISTORY
    SMOKER _____NO _____YES (# OF PACKS/DAY _____ # OF YEARS ______) EVER TRIED TO QUIT? ____
    ALCOHOL _____ NO _____ YES (TYPE _______________ AMOUNT/ LAST INTAKE: ______)
    DRUGS _______ NO _____ YES (TYPE _______________ AMOUNT/ LAST INTAKE: ______)

    RELIGIOUS & CULTURAL OBSERVATIONS _____________________________________________

    ACTIVITIES OF DAILY LIVING


    DIET & EXERCISE REGIMEN: ______________________________________________________
    ELIMINATION PATTERNS: ________________________________________________________
    SLEEP PATTERNS: ______________________________________________________________
    WORK & LEISURE ACTIVITIES: _______________________________________________________
    USE OF SAFETY MEASURES: (SEATBELT, HELMET, SUNSCREEN) _______________________________

    HEALTH MAINTENANCE HISTORY:

    YES NO DATE
    COLONOSCOPY ____ ____ ________
    DENTAL EXAMINATION ____ ____ ________
    EYE EXAMINATION ____ ____ ________
    IMMUNIZATIONS ____ ____ ________
    MAMMOGRAPHY ____ ____ ________

    FAMILY MEDICAL HISTORY


    YES NO WHO (PARENT, GRANDPARENT,
    ARTHRITIS ____ ____ SIBLING)
    CANCER ____ ____ ___________________________
    DIABETES MELLITUS ____ ____ ___________________________
    HEART DISEASE ____ ____ ___________________________
    HYPERTENSION ____ ____ ___________________________
    STROKE ___________________________

    REVIEW SYSTEMS
    VITAL SIGNS: BP: ____________ RR: _________ PR: __________ TEMP: ___________
    WEIGHT: __________
    SKIN: __________________________________________________________________________
    _______________________________________________________________________________
    HAIR: __________________________________________________________________________
    NAILS: _________________________________________________________________________
    EYES: __________________________________________________________________________
    EARS: __________________________________________________________________________
    NOSE & SINUSES: _________________________________________________________________
    MOUTH: ________________________________________________________________________
    THROAT & NECK: _________________________________________________________________
    BREAST & AXILLA: ________________________________________________________________
    RESPIRATORY: ___________________________________________________________________
    CARDIOVASCULAR & PERIPHERAL VASCULAR SYSTEM: _____________________________________
    _______________________________________________________________________________
    GASTROINTESTINAL: _______________________________________________________________
    URINARY: _______________________________________________________________________
    _______________________________________________________________________________
    MUSCULOSKELETAL: _______________________________________________________________
    _______________________________________________________________________________
    NEUROLOGICAL: __________________________________________________________________
    _______________________________________________________________________________
    PSYCHOLOGICAL: _________________________________________________________________
    REPRODUCTIVE SYSTEM: ____________________________________________________________
    NUTRITION: ______________________________________________________________________
    ENDOCRINE: _____________________________________________________________________
    LYMPH NODES: ___________________________________________________________________
    HEMATOLOGICAL:
    _________________________________________________________________

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