Republic of the Philippines

Laguna State Polytechnic University

Province of Laguna
Regular Campuses: Siniloan, Sta. Cruz, Los Banos, San Pablo City
Satellite: Nagcarlan Laguna
Forwarding Address: Santa Cruz main Campus, Santa Cruz, Laguna, Philippines

COLLEGE OF NURSING AND ALLIED HEALTH

HEALTH ASSESSMENT

PATIENT'S PROFILE

Nam Ag Date of
e: e: Birth:

Addres Contact
s: Number:

Birth Sex Race/Ethic

Place: : Origin:

Marital Religious
Status: Preferences:

Admitting Source of
Physician: Referral:

Insurance
Information:

HEALTH HISTORY

Date Source of
Obtained: Data:

Interprete
r:

Reason for seeking health

care:

PRESENT ILLNESS
1. Date of onset

2. Symptoms (type, location,

frequency, duration

3. Precipitating and or associated

factors

4. Relieving and alleviating factors

(eg. timing, setting)

5. Effect on body function

 6. Effect on ADLs and life-style

7. Treatment measures utilized (type,

frequency)

8. Effectiveness of treatment
measures

PRESENT HEALTH STATUS

1. Perceived state of health

2. Health problems

3. Physical handicaps (type,

management)

4. Prescription medications (name,

dose, route, frequency, for how
long, by whom prescribed, reason
for taking, side effects)

5. OTC medications (name, dose,

route, frequency, reason of taking,
effectiveness)

6. Home remedies used (type,

frequency, reason for used,
effectiveness)

7. Complimentary/alternative
therapies used

8. Allergies (food, drug, environment,

type of reaction and
management)
 9. immunization status (dates and
types measles/mumps/rubella,
polio, ,tetanus booster, influenza,
diphtheria, hepatitis,
pneumococcal pneumonia)

PAST HEALTH HISTORY

1. Childhood illness (strep throat,
scarlet fever, rheumatic fever,
polio, mumps, rubella, chicken
pox)

2. Serious illness (e.g. diabetes,

hypertension, heart diseases,
cancer, treatment)

3. Accident/injuries (type, date,

treatment, sequelae)

4. Hospitalizations (date, cause,

hospital, physical treatment,
length of stay)

5. Surgery (date, type. postoperative

course, name of hospital and
surgeon)

6. Obstetric history (number of

pregnancies, viable deliveries,
course of completed pregnancies,
type of labor and deliveries, sex,
weight and general condition of
the neonate, postpartum course,
number of spontaneous abortions,
number of therapeutic abortions,
age of pregnancy at the time of
each abortions)

7. Exposure to toxins and

environmental pollutions (type,
amount of exposure, untoward
effects)

8. Blood transfusion (date, number,

toward effects)
FAMILY MEDICAL HISTORY

1. Age and health, age and cause of

death of parents, grandparents,
siblings

2. Blood relative history of heart

disease, hypertension,
cerebrovascular disease, diabetes,
anemia, cancer, arthritis,
alcoholism, obesity, tuberculosis,
renal disorder, mental illness
(specific disease, age of onset,
management)

3. Communicable disease in close

family members, including spouse
and children (type, date, onset,
treatment)

4. Age and health history of spouse

and children

5. Record family history in genogram

form

Name of student: Date:

Clinical Instructor: Score: