NURSING HEALTH HISTORY
I. BIOGRAPHIC DATA
Name:
Address:
Contact Number/s:
Birth date:
Birthplace:
Age:
Occupation:
Sex:
Civil Status:
Religion:
Educational Attainment:
Ordinal Position in the Family:
Name of Spouse: (if married):
Occupation of Spouse:
Number of Children/ Spouse:
Date of Admission:
Attending Physician:
Chief Complaint/s:
Diagnosis:
II. REACTIONS AND EXPECTATIONS TO ILLNESS, HOSPITALIZATION, DIAGNOSTIC STUDIES, AND PERSONNEL
A. History of Present Illnesses (with COLDSPA or PQRST)
(Character, Onset, Location, Duration, Severity, Patterns, and Associated Factors)
P: Provoked – What causes or increases the pain? Q: Quality – Is it throbbing, dull, burning, or stabbing? R: Region –
Where on your body does the pain occur and originate from? S: Severity – Rate your pain on a scale from 1 to 10.
What are the signs or symptoms do you have since the occurrence of your illness?
When did it begin?
Where does it hurt? Point it out using your index finger. Does it radiate?
How long does it last? Does it recur?
Rate your pain on a scale from 0-10, zero, how bad is it?
What makes it better or worse?
What other symptoms occur with the pain? How does it affect you?
Have you taken any medication since you had this illness?
B. Past Illnesses
a. Childhood Illness/es
Do you experience any illness when you are child?
Do you have congenital abnormalities/birth defects?
b. Allergies
Do you have any allergies? How does your body react on it?
What medications do you usually take when having an attack?
c. Accidents/ Injuries
Do you experience any vehicular accidents or injuries? What difficulties does it cause you?
d. Hospitalization
Do you experience any previous hospitalizations? For what concern? What age?
e. Medications etc.
Do you take any medications for maintenance? What medicine is it?
Do you take vitamins or any herbal supplements? What kind?
C. Family History of Illnesses
Has there ever been a history of disease in your mother's family? How about in your father side?
Are there any smokers or drinkers in your family?
III. ACTIVITIES OF DAILY LIVING
A. Circulation (based on the Review of Systems)
Last Blood pressure?
Do you feel any chest pain? How often?
Do you feel any palpitation? When?
B. Respiration (based on the Review of Systems)
Do you have any difficulty in breathing or shortness of breath? When?
C. Food/ Fluid
How many meals do you consume each day?
What kind of food do you typically eat?
How many glasses of water do you drink in a day?
Do you occasionally drink alcohol? Which brand of liquor do you like most?
D. Elimination
How often do you void in a day? What color does it normally appear?
Are you struggling during voiding?
How often do you defecate in a day? What color and consistency does it normally appear?
E. Personal Hygiene
How often do you usually take a bath?
How often do you brush your teeth?
How often do you wash your hands?
F. Rest/ Sleep
Are you getting enough sleep? What time do you usually sleep and wake up?
Do you experience trouble in sleeping?
What routines/rituals do you go through before going to bed?
G. Exercise
What is your regular exercise?
How often do you exercise in a week?
What leisure or recreational activities do you engage in?
H. Usual Pain/ Discomfort
Do you usually suffer from pain or difficulty at times? Headaches, abdominal and muscle pain?
IV. COMPETENCIES
A. Physical
Are you able to perform activities of daily living?
What are the types of activity in the workplace/at home?
B. Emotional
Who are the most important person in your life?
Do you have difficulty in decision making?
What are the things that makes you happy upset or angry?
C. Mental
How often do you forget things?
What is your occupation?
What is your educational background?
D. Spiritual
What is your religion?
What ceremonies/rituals do you have considering you religion?
E. Social
Whom do you socialize frequently?
We have time to socialize.
F. Environmental
Where do you live?
Can you describe your surroundings?
How far is your home from community facilities/ hospitals?
