Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES
_____________________________________________________________
BACHELOR OF SCIENCE IN NURSING
NCM 101 – HEALTH ASSESSMENT
Name of Student: ______________________________ Grade: ________________
Year & Section: _______________________________ Date: _________________
PROCEDURE CHECKLIST
HISTORY TAKING
Assemble equipment:
1. Health assessment form
2. Ballpen
DON NOT
PREPARATION REMARKS
E DONE
1 Review patient’s medical record.
2 Prepare the setting.
PROCEDURES
1 Introduce yourself to the patient.
2 Verify the client’s identity.
3 Explain the procedure, purpose, and emphasize
confidentiality of information.
4 Obtain patient’s biographical information.
a. Name
b. Sex
c. Address and phone number
d. Date and place of birth
e. Nationality
f. Marital status
g. Religious or spiritual practices
h. Primary and secondary
languages spoken
i. Education
j. Occupation
k. Who lives with the client? Caregivers and
support people for the client
5 Assess the patient’s major health concern
6 Assess the patient’s history of present illness
using COLDSPA
Character of symptom or condition
Onset
Location
Duration
Severity
Pattern
Associated factors
7 Past health history
a. Problems at birth: Can you tell me how your
mother described your birth? Were there any
problems that your family told you about or that
you experienced?
b. Childhood illnesses: What diseases did you
have as a child such as measles, mumps,
chicken pox?
c. Immunization: What immunizations did you
get?
d. Acute or chronic adult illnesses:
Do you have chronic illnesses?
When were they diagnosed?
How are they treated?
e. Surgeries:
Have you ever been hospitalized or had
surgery?
What were you hospitalized for?
What type of surgery did have?
Were there any complications?
f. OB, if female: Have you ever been pregnant
and delivered a baby?
(GP TPAL)
g. Accidents/injuries:
Have you ever experienced any accident or
injury?
h. Prolonged pain or pain patterns:
Have you experienced any pain in any part of
your body?
i. Medications: Do you have maintenance
meds? Do you take any meds not prescribed
for you?
j. Allergies: Do you have allergies? food,
meds?
k. Physical, emotional, social or spiritual
strengths and weaknesses: Have you ever
been diagnosed with/treated for emotional or
mental problems?
8 Family history
9 Review of systems
a. Skin, hair and nails: skin condition, rashes,
wound, lesions, hair fall and balding
b. Head and neck: headache, swelling, stiffness of neck
c. Eyes: blurring of vision, flashing lights, eye pain and
infection
d. Ears: hearing, ringing or buzzing, earaches, drainage
from ears, dizziness
e. Mouth, throat, nose and sinuses: mouth lesions,
nasal obstruction, frequent colds
f. Thorax and lungs: Difficulty breathing; shortness of
breath during routine activities
g. Breasts: Lumps, discharge from nipples, dimpling or
changes in size
h. Heart and neck vessels: last BP, ECG findings;
chest pain, palpitations i. Peripheral vascular:
Edema of legs and feet; pain and cramping
j. Abdomen: indigestion; nausea and vomiting; pain,
hernias
k. Genitals: sexual problems; perineal lesions;
penile/vaginal discharge; pain; STIs
l. Anus and rectum and prostate: bowel habits;
diarrhea; constipation; blood in stool; pain
m. Musculoskeletal: swelling; redness; pain; stiffness of
joints
n. Neurologic: general mood; behavior; loss of
strength or sensation; memory problems
10 Lifestyle and health practices
a. Description of a typical day
b. Nutrition and weight management
c. Activity level and exercise
d. sleep and rest
e. Substance use
f. Self-concept and self-care responsibilities
g. social activities
h. Relationships
i. Values and belief system
j. Education and work
k. Stress levels and coping skills
l. Environment
Name of Clinical Instructor/Facilitator
