University of San Carlos

College of Nursing
Cebu City

I. PATIENT DEMOGRAPHIC PROFILE

Name: ______________________________________ Age/ Gender: ______ Status: _____

Home Address: ___________________________________________________________________________
Religion: _________________ Nationality: ____________ Occupation: ______________

II. HEALTH HISTORY POFILE

A. Past Medical History
1. Pediatric and Adult Illness

Date Illness Medication Remarks

2. Immunization

Date Medication Dosage Remarks

3. Hospitalization

Date Illness Medication Remarks

4. Injuries and Accidents

5. Transfusions

6. Allergies (if any)

B. Family History (support with a genogram and limit to two (2) generation if patient can recall)
C. Social and Personal History
1. Occupation

2. Number of Children

3. Military experience, foreign travel

4. Habits (tobacco, alcohol, non-prescription drugs, others)

5. Diet

6. Type of Family

7. Cultural and Religious Beliefs

8. Brief description of average day

D. Review of System (for the past 6 months). Physical Assessment
 Weight loss Fatigue Anorexia Night Sweats
General
Chills Fever Weakness

Itch Rash Lesions Bruising

Skin
Bleeding Color change

Pain Discharge Itch Vision Loss

Eyes Diplopia Excessive tearing Glasses/contact lens
Date of last exam:

Ears Earaches Discharges Tinnitus Hearing Loss

Nose Obstruction Discharges Epistaxis

Throat and Mouth Sore throats Bleeding gums Toothache Dentures

Neck and Head Swelling Dysphagia Hoarseness

III. CURRENT HEALTH PROFILE

A. Presenting complaints and medical diagnosis to include intervention done prior to hospitalization.

B. Application of Nursing Process

1. Assessment Findings (Head-to-Toe)
2. Laboratory / Diagnostic Results

Date Lab Exam Patient Results Normal Findings Interpretation / Significant