Patient Profile

NAME: EDUCATIONAL ATTAINMENT:

AGE: OCCUPATION:

GENDER: RELIGION:

STATUS: DATE AND TIME ADMITTED:

ADDRESS:

CHIEF COMPLAINTS:

ATTENDING PHYSICIAN:

DIAGNOSIS/IMPRESSION:

Health History
I. Present Illness
Describe the onset of the problem

How and when did it start

What was the setting or what was the patient doing at the time of onset?

Describe physical symptoms in terms of:

 Location

 Quality

 Quantity/severity

 Timing (onset, duration and frequency)

 The setting at which they occur

 Factors that aggravated or relieved the symptoms and associated manifestations.

 What treatment taken at home? How did the patient respond?

II. Past Health History

General state of health (as the patient perceives it)

Childhood illnesses experienced:

Measles
Mumps
Chicken Pox
Rheumatic fever
Polio

Immunizations received:
DPT
Measles
Mumps
BCG
Others
Adult illness.

 Type

 How treated?

 Recovered or not?

Operations:
Injuries:
Allergies:
Current medications taken: (Including home remedies, non-prescription drugs, vitamin/mineral supplements and medicines
borrowed from family or friends. Asks about frequency and dosage.)

III. Family History

Illnesses experienced by other members of the family.

Age and health or age and cause of death.

Occurrence within the family of any of the following conditions

Diabetes
Tuberculosis
Arthritis
Anemia
Mental illness
Heart disease
Cancer

Alcoholism
Drug addiction
Smoker

IV. Birth and Obstetrical History

Menarche
GPTPAL
EDC
AOG
previous use of contraceptives?

Prenatal (Maternal health before or during pregnancy. Illnesses experienced by mother during pregnancy, complications, drugs
taken, duration of pregnancy.)

Natal (Nature of labor and delivery. Birth order. Birth weight. Complications during birth. Anthropometric data, Ballard scoring)

Neonatal (Onset of respirations, estimation of gestational age. Specific problem with feeding, respiratory distress, cyanosis,
jaundice, anemia, congenital anomalies, infection.)
 V. Feeding History
Infancy.

Breastfeeding (frequency and duration of feedings, use of complimentary or supplementary artificial feedings, difficulties
encountered, timing and methods of weaning.)

Artificial feeding (Type of formula, concentration, amount and frequency of feeds, feeding difficulties, timing and method of
weaning. Vitamin supplements given.)

Supplementary feeding (types and amount of food given, when (age) introduced, infanot’s response.)

VI. Growth and Development History

(FOR PEDIA)

Physical growth:
Height
Weight at birth, ages 1, 2 5, and 10 years.
History of rapid or slow gains or losses in weight
Tooth eruption and loss pattern.

Developmental milestones: (Ages at which patient held up his head in prone position, rolled form front to back, sat with
support/alone, walked, said first word, combination of words, and sentences, tied own shoes, dressed without help.)

Social development:

Sleep patterns (amount and patterns during day and at night, bedtime routines, type of bed and its location, nightmares, terrors
and somnambulating)

Toilet training (age, methods used, difficulties encountered, terms used for defecation and urination).

Speech (hesitations, stuttering, baby talk lisping, estimated number of vocabulary.)

Habits (head banging, thumb sucking, nail biting, pica, ritualistic behavior, tantrums, aggression, withdrawal)

Schooling (age entered school, achievement. Other information)

Personality (degree of independence, relationship with parents/siblings, activities, and interests, special friends, major assets and
skills)
VII. Patterns of Functioning

1. RESPIRATORY Inspection: Results of chest X-ray

a. Hx of cough productive Presence of cough none Results of sputum
not productive not productive examination
b. Hx of asthma productive Medications being taken
Hx of Bronchitis Color: greenish bloody
Hx of emphysema yellowish pinkish
c. Hx of dyspnea: exertion others: ____________
during rest Cough interferes with rest.
d. Hx of PTB or cough more than Colds Sneezing
2 weeks nasal discharges
relief measures done: with tracheostomy
(Specify)______________ respiratory aids use:
(specify)____________
with CTT
e. Non-smoker
smoker: Respiratory rate & rhythm & pattern
amount consumed Per day; RR: ____cpm
____packs ____sticks normal/breath effortless
How long: ____years Abnormal:
f. Hx of surgery related to lung use of accessory muscles
problem: _____________ rapid swallow breathing
g. difficulty of breathing during (tachypnea)
sleep rapid deep breathing-hyperpnea,
Use of more than one pillow to hyperventilation)
sleep slow breathing (bradypnea)
h. exposure to environmental Cheyne stokes breathing
inhalants (chemicals, fumes) obstructive breathing
asymmetrical lung expansion
symmetrical lung expansion

Contour of chest

Palpation:
Percussion:

Auscultation of Lung sound

normal breath sound/clear

presence of adventitious breath sound

2. CIRCULATORY BP: ___mmHg ECG results

History of: PR: ___bpm Blood chemistry
HPN; dizziness; heart HR: ___bpm Hematology
problems:(specify) _______ Normal HR Medications taken
fainting spells, palpitations, heart tachycardia
defect, bradycardia
Hx of murmur regular rhythm irregular
Hx of heart surgery Normal pulse
chest pains weak/small pulses
Location: large/bounding pulses
Rating scale 1-10: ____ bigeminal pulses
radiating not radiating presence of swelling: where: _______
Duration: _____mins. varicosities of extremity/ies
associated symptoms: nausea, discolored parts: where: _________
vomiting, sweating Cyanosis pallor
relief measures done: cold extremities warm extremities
_______________________________ edema: where: _____________
Causes of attacks: ____________ pitting non-pitting
irregular heartbeat circumference of edematous
tachycardia Extremities: _____cm.
bradycardia Redness in pressure areas: where: ___
Swelling(where): ______________ complaints of headache (severity,
discoloration(where): ___________ location): __________________
edema experienced: associated symptoms of headache
associated with what: ____________ (specify): _____________
chest pains (severity,
quality):__________________
easy fatigability,
palpitations
tightness of chest
Capillary refill: ______secs.
Color of nail beds:
cyanotic pale
Color of mucus membrane:
____________
heart murmurs
high pitch medium low
Quality: blowing rumbling
harsh musical
Nails: pale nail bed
pink nail bed
clubbing on nails

3. FOOD AND FLUID INTAKE General state of health Diet prescribed, fluids
prescribed, oral, parenteral,
Usual foods taken Body builds Results of GI tract x-rays,
liver function tests, blood
Nutritional state sugar level.
Meal pattern

Height: ____ft. Weight: ___kg.

How many meals does he take each day? Nutritional status of:
Skin:
poor skin turgor.
Time mildly dehydrated.
moderately dehydrated.
severely dehydrated.
Food allergies evenly distributed fine hair
Edema: pitting non-pitting
Eczema (scaling of the skin)
Food preferences and dislikes Dry skin

No. of glasses of water taken each day. color of skin:

dark skin white skin
Other beverages taken,
Texture:
Does he take alcohol? Type? Average? rough/thick
smooth/soft
Amount consumed/session, frequency, Temp. & moisture of skin:
for how long has he been drinking? warm cold hot
wet oily dry
Pedia patients: include feeding hx Scalp/hair:
dandruff
Brittle hair
scaly dry
Hydration of mucus membranes:
dry moist
Mouth: lips:
 dentures dry
dental carries moist
cracked

nausea
vomiting (Amount): _______
frequency: _______
loss of appetite
swallowing difficult
abdominal pain(scale 1-10): ____
dysphagia

Actual foods taken (specify

quality/quantity):
_______________________
Rate of IVF: ______
on Parenteral feeding
With NGT

4. ELIMINATION Date of last BM: _________________ Results of UGI series, barium

Char. Of stool: soft hard enema, etc.
How many times does patient void/day? Color: brownish black tarry Stool exam result.
(specify): __________ others: ______________ Urinalysis result.
color: melena Kidney function tests
straw to amber constipation(duration): ____days
orange remedy: ________________
brownish with colostomy
reddish diarrhea: frequency: _________
smoky-colored urine
Amount: (specify): ____ Urinary frequency:
History of: Amount: (specify):
indigestion dysuria ____________________
nausea dribbling urgency
vomiting dysuria
incontinence
Constipation (Cause): _______ polyuria
relief done: __________ Foley in place
diarrhea (cause): _________ Urine color:
relief done: _________ straw to amber orange
brownish reddish
BM per day(specify): ____ smoky-colored urine
Usual time: morning perspiration: profuse not
afternoon Passage of flatus
evening abdominal distention
abdominal tenderness
Char. Of stool: soft hard hernia
Color: brownish black tarry
others: ______ Sounds in the abdomen: _______
taking aids for elimination hematemesis(amount): _____
specify: ________ frequency: _______
abnormalities of anus noted
specify: ________
5. REGULATORY MECHANISMS Temp.: ____°C (Oral, rectal. Axilla) Results of blood examination
Skin: dry skin moist indicative of infection
Fever before? associated with? Any chills? pale cyanotic process. Medications taken.
Relief measures? hot to touch cold/clammy
Menarche, interval, no. of days. LMP? perspiration noted
Menopause? Hot flushes Face: flushed rashes
Birth control pills. Hormonal replacement twitching
taken. paralysis
EDC, onset of contractions. Have OB-GYNE
membranes ruptured? FHT: ______bpm
Rate of contractions; ____per min.
duration: ____________
Frequency: ___________.
Intact membranes  not

Vaginal bleeding none

Height of fundus: _____cm.
Char. of fundus:
firm soft /boggy
Appearance of lochia:
rubra serosa alba
Amount: _________
Breast enlargement
tenderness
Male/female genitalia. (Describe char.)
___________

6. HYGIENE General appearance, neat, dirty? Toiletries use.

Unkempt? Brand of soap,
How often does patient take a bath? toothbrush/toothpaste,
Time? Skin condition-scars, lesions? Shampoo use.
Shampoo use? Often? Brush teeth?
Change clothes, etc. HEAD: hair distribution and texture.
Allergies to soap, shampoo. Scalp- secretions? Lesions? Dandruff,
Any beliefs/practices related to personal pediculosis?
hygiene.
Skull: contour, size

Nails- clean or dirty, short or long?

Mouth- clean? Odors? Halitosis?

Unpleasant odor of patient?

7. ACTIVITY & EXERCISE Physical bearing X-RAY results for fractures,

Stature dislocations. Lab results
Usual exercise at home: ________ Gait which would signify musculo-
frequency & time done: _________ Posture skeletal abnormalities.
Joint stiffness experienced. Movement
Hx. Of gout arthritis, Extent of range of joint motion?
Paralysis: _________ Limitations of movements?
since when: _______ Fractures?
Prosthetic/devises Joint stiffness
Aids to mobility: _________ Contracture deformities?
Dislocation? Muscle pain?
Cramps?
Amputated parts?
Use of crutches, cane, or other walking
aids.

Neck: symmetry of musculature

Abnormal masses
 Swelling
Enlargement of thyroid glands,
Presence of lymph nodes
Vein prominence
Scars
Moles
Stiffness of neck?

8. REST AND SLEEP Looks tired Rest prescription of physician

sleepy
No. hours usually slept: ______ eye bags/puffiness around
Time of arising and retiring: ____ difficulty in sleeping
Insomnia Possible cause: _________
Daytime naps Actual no. of hours slept: ______
How long: ______ Interrupted sleep
Favorite sleeping position; frequent yawning
supine prone side-lying decreased attention span
No. of pillows used: ____pcs.
use Mosquito net
Bedtime rituals
Describe: ___________
snores
teeth grinding
talks when asleep

9.COMMUNICATION AND SPECIAL EYE: distribution of lashes, condition of Results of sight and hearing
SENSES eyelids. Color of sclera, dryness or tests.
lacrimation. Characteristics of
Right handed left handed conjunctiva, pupils, eye control
Use of eye glasses movement, lens, presence of ulcerations,
Hearing aids abrasions, foreign body, eye infection,
For how long the patient is wearing growth, cataract
these? _______
Visual and auditory disturbances:
yes no

Speech disturbances:
yes no EARS: shape of pinna, legions, swelling,
Dialect or language spoken: _______ tenderness of mastoid process, external
canal, discharges, foreign bodies,
earache? Difficulty of hearing.

NOSE: patency, condition of septum, and

turbinates, adenoids? Epistaxis?

VOICE: manner of talking? Mannerisms?

Coherence of expressions, presence of
glasses and contact lenses, hearing aids
and speech defects.
10.COGNITION & PERCEPTION (sensory) Oriented: Results of neurological
exams. Or tests
Person time place

HX of convulsions Level of consciousness

yes no alert restless lethargic

Hx of loss of consciousness comatose(GCS) : ____

yes no Suffering from seizures while in your

care? yes no
Hx of epilepsy
Response to stimuli:
yes no
Tactile yes no
onset (age): _____years old
Verbal yes no
Medications taken
coherence of expression:
yes no
yes no

11. PAIN AND DISCOMFORT Facial grimace Check the physician’s record
for symptoms of which the
Pain and discomforts frequently guarding
patient complains.
experienced:
Pain scale (0-10): ____ Medications taken.
yes no
affect other patterns:
Describe manifestation: _________
yes no
Relief done: _____________
Discomfort felt:
Does he know the cause?
yes no
yes no
Describe: ______
Describe: ______________

12. RECREATION AND DIVERSION Any evidence of boredom? Presence of entertainment

appliances, gadget, devices.
What is done for fun? ___________ yes none

Hobbies: ____________ Describe: ___________

Interest he would like to pursue: What does he want to do to pass his

time? ______________
Describe: _______

(Children) what is their favorite plaything?

________

13. RELIGIOUS LIFE Religious medals worn Advices from religious

ministers.
Religious affiliation yes none

Roman Catholic Describe: _______

Islam Need for religious counselor:

others: ___________ yes none

Ability to meet own spiritual needs.

Religious belief and practices (esp. those yes none

that may affect his care and health), diet,
days of worship, holy day: describe
___________
14. COPING MECHANISMS What are the patient’s attitudes? Reports of psychiatric
evaluation
What is done when facing stressful
situation? _________
Mood?
What do you do when?

Angry: ___________________
How he is coping with his illness?
Frightened: ________________

Whose advice is sought when problems

Coping mechanisms observed during
occurs?
stressful situation/circumstances.
parents siblings

spouse others: ________

Post-natal pts; response to motherhood.

Ways of handling the baby(case)

15. ROLE AND RELATIONSHIPS (for Adult Support of family/friends

client)
Behavior towards roommates. Visitors,
Work role- type and hours of work. staff, acceptances of sick role or other
role change. Need for teaching and
Feelings about his work.
counseling.
Family roles

Members of household

Social roles

Anybody special he wants to see?

Cultural prescriptions re: health care and

practices