Patient profile

PATIENTS PROFILE
NAME: Mrs. VillegasAGE: 69y/oSEX:
FemaleADDRESS: Fairlaine subdivision,
Tarlac, CityBIRTHPLACE:
TarlacNATIONALITY: FilipinoRELIGION:
Roman CatholicCIVIL STATUS:
MarriedBIRTHDAY: June 11,1939DATE AND
TIME OF ADMISSION: July 14,
2008/9:01amFINAL DIAGNOSIS: Massive
ascites 2 to portalhypertension 2 to CLD

1. General appearance:a.Hair:
_____________________________________
____________ _ b.Skin:
_____________________________________
____________ _ c.Nails:
_____________________________________
____________ d.Body odor: _________
SUBJECTIVE1.How would you describe your usual
health status?Good__ Fair__ Poor__ 2.Are you
satisfied with your usual health status?
Yes__ No__ Source of dissatisfaction:
____________________________ 3.Tobacco use?
No__ Yes__ Number of packs per day?
_______________ 4.Alcohol use? No__ Yes__
How much and what kind? ________________
5.Street drug use? No__ Yes__ What and how
much? _________________ 6.Any history of
chronic disease? No__ Yes__ Describe:
_______________
_________________________________________
____________ ______ 7.Immunization history:
Tetanus__ Pneumonia__ Influenza__ MMR__
Polio__ Hepatitis B__ 8.Have you sough any health
care assistance in thepast year? No__ Yes__ If
yes, why?
_________________________________________
________ 9.Are you currently working? No__

Yes__ How wouldyou rate your working

conditions? (e.g. safety, noise,space, heating,
cooling, water, ventilation)?Excellent__ Good__
Fair__ Poor__ Describe
anyproblemareas:__________________________
_

________________ 10.How would you

rate living conditions athome? Excellent__
Good__ Fair__ Poor__ Describe
anyproblem areas:
___________________________________
_________________ ______ 11.Do you
have any difficulty securing anyof the
following services?Grocery store: Yes:__
No:__; Pharmacy: Yes__ No__;Health Care
Facility: Yes:__ No:__; Transporation:
Yes:__ No:__; Telephone (for police, fire,
ambulance): Yes:__ No:__; If any
difficulties, note referral here:
___________________________________
__________________ _
___________________________________
__________________ _____
12.Medications (over-the-counter
andprescription)NameDosage
Times/DayReason Taken asOrdered
Yes__No__
Nursing\Nursing Forms\Gordons 11
Functional Health Patternsaoih0718
13.Have you followed the
routineprescribed for you? Yes__ No__

Why not?
___________________________________
___ 14.Did you think this prescribed
routinewas best for you? Yes__ No__
What would be better?
____________________________
15.Have you had
anyaccidents/injuries/falls in the past
year?No__ Yes__ Describe:
___________________________________
___ 16.Have you had any problems with
cutshealing?No__ Yes__ Describe:
___________________________________
___ 17.Do you exercise on a regular
basis?No__ Yes__ Type & Frequency:
______________________________
18.Have you experienced any ringing inthe
ears: Right ear: Yes__ No___ Left ear:
Yes__ No__ 19.Have you experienced any
vertigo: Yes__ No__ How often and when?
___________________________________
________________ ______ 20.Do you
regularly use seat belts? Yes__ No__
21.For infants and children: Are car
seatsused regularly? Yes__ No__ 22.Do
you have any suggestions orrequests for
improving your health? Yes__ NoDo you
have any suggestions orrequests for
improving your health? Yes__ No

Describe:
___________________________________
___
___________________________________
________________ ______ 23.Do you do
(breast/testicular) self-examination? No__
Yes__ How often? ___________________

NUTRITIONAL-METABOLIC
PATTERNOBJECTIVE1.Skin
examinationa.Warm__ Cool__ Moist__
Dry__ b.Lesions: No__ Yes__ Describe:
_______________________________
c.Rash: No__ Yes__ Describe:
_________________________________
d.Turgor: Firm__ Supple__ Dehydrated__
Fragile__ e.Color: Pale__ Pink__ Dusky__
Cyanotic__ Jaundiced__ Mottled__
Other______________________________
________________ ______ 2.Mucous
Membranesa.Mouthi.Moist__ Dry__
ii.Lesions: No__ Yes__ Describe:
__________________________ iii.Color:
Pale__ Pink__ iv.Teeth: Normal__
Abnormal__
Describe:____________________
v.Dentures: No__ Yes__ Upper__ Lower__

Partial__ vi.Gums: Normal__ Abnormal__

Describe:____________________
vii.Tongue: Normal__ Abnormal__
Describe:___________________
b.Eyesi.Moist__ Dry__ ii.Color of
conjunctiva: Pale__ Pink__ Jaundiced__
iii.Lesions: No__ Yes__
Describe:___________________________
3.Edemaa.General: No__ Yes__
Describe:___________________________
____ Abdominal girth:
___inchesb.Periorbital: No__ Yes__
Describe:___________________________
__ c.Dependent: No__ Yes__
Describe:___________________________
__ Ankle girth: Right:__ inches;
Left__inches4.Thyroid: Normal__
Abnormal__ Describe:
_________________________ 5.Jugular
vein distention: No__ Yes__ 6.Gag reflex:
Present__ Absent__7.Describe an average
days fluid intake for you.
_____________________
_________________________________________
____________ ______ 8.Describe food likes and
dislikes. _________________________________
_________________________________________
____________ ______ 9.Would you like to: Gain
weight?__ Lose weight?__ Niether__ 10.Any
problems with:a.Nausea: No__ Yes__ Describe: