I.
Personal Data
Name:
Address:
Age:
Sex:
Civil Status:
Religion:
Birthday:
Birthplace:
Attending Physician:
Chief Complaint:
Medical Diagnosis:
II. PAST MED HISTO
- Have you undergone any surgery for the past 3 years?
III. FAM HISTO
AGE SEX RELATIONSHIP CONDITION/DISEASE
IV. SOCIAL HISTO
● Do you smoke?
- How often?
- No. of years smoking?
● Do you drink alcohol bev?
- How often?
- No. of years?
● What is your current work? Sapat naman po ba yung sahod?
V. ENVIRONMENT HISTO
● Malapit po ba kayo sa ilog/construction sites?
● May bintana po ba sa bahay niyo?
● Ilan po ang kwarto sa bahay niyo?
● Sarili po ba o umuupa lang?
● Source of water?
● Drinking water?
VI. IMMUNIZATION
Patterns of Functioning Questions
Health Perception Pattern 1. Do you consider yourself healthy? What is “healthy” for you?
2. When there is something wrong with your body or whenever you feel sick,
what do you first do? Who and where do you seek help?
3. Most important thing you do to stay healthy?
Nutritional - Metabolic 1. Do you have any food allergies?
2. How many meals do you eat per day?
3. Do you have any diet? What is it?
4. Are there any foods that you avoid because it causes problems?
5. Are you more on carbs or veggies and fruits?
6. In every meal, do you also eat fruits or veggies?
7. How much water do you consume in a day?
Elimination Skin & Perspiration
1. Do you have an issue towards sweating? May it be too excessive?
Bowel Excretion
2. May I know how frequently you take bowel excretion in a day? Is there a pain?
3. How often is your bowel movement in a week?
Bladder Excretion
4. How often do you urinate in a day?
5. Do you experience any difficulty in peeing/urinating?
6. Is there any alarming discomfort, odor, appearance, frequency regarding
bladder excretion?
Activity - Exercise 1. Do you exercise regularly?
2. What type of exercises do you do?
3. What activities do you engage in during your leisure and recreation time?
4. How often do you engage in exercise?
Cognitive - Perceptual 1. Do you wear eyeglasses? Are they prescribed or not?
● (If the client wears eyeglasses) How long have you had them?
● When was your last eye check-up?
● Do you change your eyeglasses regularly?
2. Do you find it hard to recall information? recognize people and objects?
differentiate people and objects?
3. Experienced any difficulties or discomfort on your ear?
4. Any kind of speech problems?
Sleep - Rest 1. What time do you usually sleep?
2. What time do you usually wake up?
3. How long do you think you usually sleep at night?
4. Do you have difficulty falling asleep?
5. Do you take naps within the day?
● When do you usually take naps?
● How long are your naps?
Self Perception/ Self 1.Give me three words that you feel describe your personality.
Concept
2. Do you feel positive or negative about your current health status?
3. Do you feel confident in your body?
4. Are there things that you don’t like about your body?
Role Relationship 1. Do you live alone or are you living with anybody?
2. Ano po yung mga quality time niyo with your family?
3.How can you define your support system?
Coping/Stress Tolerance How do you cope with stress?
For you, Who is the most helpful intalking things over?
Value-Belief What is your religion? Nagsisimba pa rin po ba tayo daily?
