Adventist University of the

Philippines
COLLEGE OF NURSING
MNHA 510-Advanced Health Assessment

Health History Form

Date: February 4, 2023 Time: 6:15 pm

Client Information
Name (Initials): NJEC Age: 22

Birth Date: February 23, 2000 Gender: Male

Address: Purok-1, Pines, Oroquieta City, Misamis Occ. Nationality: Filipino

Phone Number: 09161324789 Marital Status: Single

Educational Level: College Level

Health Insurance Provider: AXA Insurance

Source and Reliability of Information:

Current Health Status

Chief Complaints: The one or more symptoms or concerns causing the patient to seek care.
Make every attempt to quote the patient’s own words.

o Pain on left lower back.

o Nauseous.
o Patient said as claimed: “Sakit kaayo akong likud, sa ilalum dapit, tapos naa time
nga kasukaon ko”

History of Present Illness (“PQRST”)

 P: precipitating factors (What provokes the symptoms?)

o When he woke up, he felt sudden pain on his left lower back. (Pag mata nako sa
buntag, nikalit lang sakit akong likud, dri dapit)
 Q: quality (Describe the character and location of symptoms.)
o Sharp-sudden pain on his left lower back.
 R: radiation (Does the symptom radiate to other areas of the body?)
o Does not radiate to any part of the body
  S: severity (Ask the patient to quantify the symptom[s] on a scale of 0-10, with 0 being
absence of the symptom and 10 being the most intense.)
o Patient as claimed: pain scale of 7/10 (“Kung e-scale jud mga 7/10 kasakit”)
 T: timing (Inquire about the onset, duration, frequency, etc.)
o Upon waking up, felt the sudden pain, then with on and off pain.

Past Medical History:

Patient’s definition of health and perception of current health status.

o “Health is physically, socially, mentally, spiritually, emotionally balanced”.

o “I have realized that I have to remind myself to drink water, because I usually
forget, especially after doing vigorous activities”.

Childhood illnesses

o Experienced mumps, chickenpox, and cough & colds.

Major adult illnesses/conditions

o Experienced UTI.

Allergies

o No known allergies to foods, medications, environmental agent.

Medications

o No prescribed medications taken, or over the counter medicines. Only vitamin C.

Injuries

o No major or minor injuries like head injuries, fractures, or auto accidents.

Hospitalizations

o Experienced hospitalizations due to high grade fever and UTI.

Transfusions

o Have not undergone any transfusions.

 Immunizations

o Completed childhood immunization

o Fully vaccinated Covid-19 vaccine (Sinovac) last December 2020.
o Tetanus Toxoid shot last November 2022.

Screening exams

o Physical screening exams every semester since his first year in college.

Psychiatric/mental health

o None. As stated: “I'm in a current state of wellbeing where I feel good and can
carry on with my daily activities with ease.”

Family History (Use Genogram)

Personal/Social History:
Cultural Background

Home Conditions. Note type (e.g., private home, walk-up apartment)

o “We have our own private home. Tapos among balay daplin sa dalan (Our home
is situated near the highway). I have 2 siblings and we each have our own
rooms.”
o “Ang house namo, kay duol ra sa mga transportation, dili lisud sakay” (Our
house is very accessible to public transportation).

Safety. Assess and record data about the patient’s actual or potential exposure to
environmental hazards as well as her or his safety practices.

o “When I do my outdoor or sports activities, I see to it that I always wear my

safety gears. Tapos kung mag bike ko, I make sure nga e follow ang road signs
and regulations, defensive driver sad ko” (When I do my outdoor or sports
activities, I see to it that I always wear my safety gears. If I ride my bike, I make
sure to follow the road signs and regulations, I’m also a defensive driver).

Exercise. Note type, intensity, duration, and frequency.

o He exercises everyday either cycling, or jogging for about 30 mins to 1 hour.

Sleep. Note the usual number of hours per 24-hour period.

o “Sa 24 hour period, mga 6 hours ra akong sleep lately. Daghan man gud ko
requirements, labina nga 4th yr nako” (In a 24 hour period, lately I slept only for
around 6 hours. I have a lot of requirements especially that I am a 4th year
student).

Drug and alcohol use. For all the substances addressed in this section, the social
conditions of use often play a major role in determining amount and pattern of
consumption.

o Haven’t tried any drugs or alcohol.

Social support. How does the patient perceive her or his level of social support?
Who/what are the patient’s primary sources of support?
 o Moderate social support. “Akong feeling kay naa ra sa middle akong support, dili
kaayo full gyud, both from family and friends” (I can say that the support I’m
getting is only at the middle, not so full, both from my family and friends).
o My primary source of support is my family and friends.

Stress and anger management. Ask the patient to identify sources of stress in his or her
life and to describe strategies used to cope with stress.

o “Akong major source of stress gyud karon kay school requirements. Then naa
pud sa family, kay naa me gamay nga family problem nga gina atubang karon”
(My major source of stress today is school requirements. Then some from my
family because we have little family problem that we are facing today).
o How to cope: “I do outdoor activities, or sports. Hilig jud ko mag saka2 bukid,
maka relieve sa stress gyud” (I’m fond of mountain climbing, it really can relieve
stress).

Recreation/travel. Which interests or hobbies the patient have?

o Hobbies: jogging, hiking, climbing, cycling

Cultural beliefs and practices. How do cultural beliefs and practices influence the
patient’s healthcare behaviors?

o He quoted: “As long as we can treat it at home, we will not go to the hospital”.
He further stated “Ayha rajud me pa hospital kung kailangan na, or lala najud.
(We go to the hospital if the situation gets worse).”
o He said, “healthy man me ug food, ga practice jud me eat ug vegetables, seldom
lang ga meat or fish (We eat healthy food, and practice eating vegetables, we
seldom eat meat or fish)”.

Spirituality. What role do spiritual beliefs and practices play in the patient’s life?

o As an active Seventh-day Adventist, he goes to church regularly. He is also part

of Masterguide.
o “I believe in the saying about the golden rule, do unto others what you want
others do unto you. Mao ng need gyud kindness sa people around you” (That’s
why kindness is important to people around you).

Review of Systems: Includes series of review-of- system questions going from “head to toe”.
For each regional “system” you will ask: “have you ever had any…?

General- usual weight, recent weight change, clothing that fits more tightly or loosely
than before: weakness, fatigue, or fever.

o No changes in his weight.

o Haven’t experienced any weakness or fatigue.
o Experienced high grade fever when he was a child.
Skin: Rashes, lumps, sores, itching, dryness changes in color; changes in hair or nails;
changes in size or color of moles.

o No noticeable changes.

Head, Eyes, Ears, Nose, and Throat (HEENT): Head: headache, head injury,
dizziness, lightheadedness. Eyes: vision, glasses or contact lenses, last examination, pain,
redness, excessive tearing, double or blurred vision, spots, specks, flashing lights,
glaucoma, cataracts. Ears: hearing, tinnitus, vertigo, earaches, infection, discharge. If
hearing is decreased, use or nonuse of hearing aids. Nose and Sinuses: Frequent colds,
nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble. Throat: d
examination, sore tongue, dry mouth, frequent sore throat and hoarseness.

o Head: no hx of head injury, dizziness, or lightheadedness.

o Eyes: no difficulty with vision, clear eyesight, 20/20 vision
o Ears: no known problem in hearing, tinnitus, vertigo, earaches, infection,
discharge.
o Nose and sinuses: no history of nasal stuffiness, discharge, or itching, hay fever,
nosebleeds, sinus trouble. Only seldom colds due to weather changes.
o Throat: experienced early morning voice hoarseness. No known other problems.

Neck: “Swollen glands”, goiter, lumps pain, or stiffness in the neck.

o Had not experienced any swollen glands, goiter or lump pain. Had experienced
stiffness in the neck more than once.

Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination practices.

o No known problem

Respiratory: Cough, sputum (color and quantity) hemoptysis, dyspnea, wheezing,

pleurisy, and last chest x-ray.

o Clear breath sounds. No hx of severe cough.

Cardiovascular: “Heart trouble”, high blood pressure, rheumatic fever, heart murmurs,
chest pain or discomfort, palpitation, dyspnea, orthopnea, paroxysmal nocturnal dyspnea,
edema, results of past ECG or other cardiovascular tests.

o Haven’t experienced any of these symptoms or problems.

Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea. Bowel movements,

stool color and size, change in bowel habits, pain with defecation, rectal bleeding or
black tarry stool, hemorrhoids, Constipation, diarrhea, abdominal pain, food intolerance,
excessive belching or passing of gas. Jaundice, liver or gallbladder trouble, hepatitis.

o “So far, wala pako ka try gyud ana nga mga problem, pero naay times mag sakit
a kotiyan, pero mawala raman, feel nako kanang times nga maka miss ko ug
meals. Pero all in all, okay raman akong tiyan” (So far, I haven’t tried any of that
 problems, there are times when I have stomach ache, but it’ll just go away, I feel
that those are the times when I missed eating meals. But all in all, my stomach is
okay).

Peripheral vascular: Intermittent claudication; leg cramps; varicose veins; past clots in
the veins; swelling in calves, legs or feet, color change in fingertips or toes during cold
weather, swelling with redness or tenderness.

o No history to any of these symptoms.

Urinary: Frequency of urination, polyuria, nocturia, urgency burning or pain during

urination, hematuria, urinary infection, kidney or flank pain, kidney stones, ureteral colic,
suprapubic pain, incontinence, dribbling.

o Urinating often, with small amounts of urine

o Often feels pain when urinating
o Flank pain
o Feeling the need to urinate despite having an empty bladder

Genital: Male: Hernias, discharge from sores on the penis, testicular pain or masses,
scrotal pain or swelling, history of STDs and treatments, condom use. Female: Aged of
menarche, regularity, frequency and duration of periods, amount of bleeding, bleeding
between periods or after intercourse, last menstrual period, dysmenorrhea premenstrual
tension. Age of menopause, menopausal symptoms, post menopausal bleeding. Vaginal
discharge, itching, sores, lumps, STDs. Number of pregnancies, number and type of
deliveries, number of abortion, complications of pregnancies and birth control methods
(if applicable).

o No history to any of these problems.

Musculoskeletal: Muscle or joint pains, stiffness, arthritis, gout, backache, If present

describe location of affected joints or muscles, any swelling, redness, pain, tenderness,
stiffness, weakness or limitation of motion or activity; include timing of symptoms. Neck
or low back pain. Joint pain with systemic features such as fever, chills, rash, anorexia,
weight loss or weakness.

o “Naay times nga mag sakit akong muscles or joints, especially kanang dili ko
maka warm up before doing outdoor or sports activities. Pero ma ulian raman
dayun sad” (There are times that I feel pain on my muscles or joints, especially if
I don’t do my warm-ups before doing outdoor or sports activities. But the pain
will be gone right away).
o “Karon, sakit akong kilid sa likud diri sa left, feel na gyud nako sa UTI na ni.
Aside sa ani karon, wala naman lain nga sakit sa akong lawas” (My lower
backside now is painful, I feel it’s because of my UTI. Aside from this, there are
no other symptoms or pain on my body).

Neurologic: Changes in mood, attention, or speech; changes in orientation, memory,

insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness,
paralysis, numbness or loss of sensation, tingling or “pins and needles”, tremors or other
involuntary movements, seizures.

o Haven’t experienced any of these symptoms stated above.

Hematologic: Anemia, easy bruising or bleeding, past transfusions, transfusions

reactions

o No known problem from these.

Endocrine: “Thyroid trouble”, heat or cold intolerance, excessive sweating, excessive

thirst or hunger, polyuria, change in glove or shoe size.

o Haven’t experienced any of these symptoms stated above.