Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

Comprehensive Health History

Biographical Data

Questions Findings

Name
Age
Gender
Address
Date of birth
Place of birth
Nationality or ethnicity
Marital status
Primary and secondary languages spoken, written and
read; birth language
Educational level
Occupation and working status
Who lives with the client?
Significant other
Caregivers and support persons of the client
Attending Physician
Reason for Admission
Admitting Diagnosis
Final Diagnosis
Source of Information
Setting
Chief Complaint (Reason for seeking health care?/ Most
current health concern at this time.)

History of Present Illness (use COLDSPA when

appropriate)

1. Character of symptom or condition

2. Onset (when did it begin; better? worse?

same?

3. Location (where and does it radiate?)

4. Severity (on scale of 1-10)

5. Pattern (what makes it better? worse?)

6. Associated factors (other associated symptoms? Effect

on leisure or exercise?)

How did the parents/guardian respond to patient’s

symptoms?
What are the concerns of the parents/guardians? Any other
problems?

Past Medical History

Questions Findings
Childhood

Eating habits:
• Likes and dislikes, specific type and amount eaten? •
Parental attitude towards eating in general and toward his
child is under or over eating; parenteral response to feeding
problems?
• Food intake in the childhood feeding pattern? (1-2 weeks)
Childhood / Adult illnesses

Adult Illnesses
 Include any recent illnesses (i.e. infection)

Surgeries
Year Reason Hospital

Injuries
Year Reason Hospital

Trauma
Year Reason Hospital

Screening Tests or Exams

(-) ENBS is normal
(+) Must be brought back to his/her health practitioner for
further testing
Immunizations
Birth BCG, HEPA B, OPV
6 weeks Hepa B, DTP, IPV, HIB, Rota V, PCV
10 weeks DTP, IPV, HIB, Rota V, PCV

14 weeks DTP, IPV, HIB, Rota V, PCV

6 months Hepa B, OPV

9 months OPV, MMR
9-12 months Typhoid
12 months Hepa A
Others: (Vaccine Name, Date)

Allergies
Questions Findings
Prompt with common allergies, if needed (aspirin, sulfa,
penicillin)Make sure you include the reaction
Seasonal, environmental, contact and food allergies

Medications
Questions Findings
Prescribed medications (also determine when started and
if any doses have been changed recently)
Drug name Dose & Frequency Route Reason Length of Taking It

Maintenance Drugs’ Name Dose & Frequency Route Reason Length of Taking It

 Compliance / remember or able to take it (can ask how

the patient remembers to take it)

Remind of typically “forgotten” medications:

 Samples

 Creams/ointments
 Eye/ear medications
 Inhalers
 Recent / current antibiotics
 Clarify any PRN medications for frequency of use

Over‐the‐counter medications

 Herbal / natural products (including household

remedies)

 Vitamins

Family History
Parents
Name: Name:
Age: Age:
Occupation: Occupation:
Illness: Illness:
Siblings/ Children/ Spouse
Name: Age: Occupation: Illness:

Personal Medical History

Alcohol abuse Bleeding disease Growth/development disorder Hives Rectal cancer
Anemia Blood clots Hearing impairment Kidney disease Reflux/GERD
Anesthetic complications Blood transfusions Heart attack Liver Disease Seizures/convulsions
Anxiety disorder Bowel disease Heart disease Lung Cancer Severe allergy
Arthritis Breast cancer Heart pain/angina Lung/Respiratory Disease Skin cancer
Asthma Cervical cancer Hepatitis A, B, C Mental illness Suicide attempt
Autoimmune problems Colon cancer High Blood Pressure Migraines Thyroid problems
Birth defects Depression High Cholesterol Osteoporosis Ulcer
Bladder problems Diabetes HIV/STD Prostate cancer Visual impairment
Other disease:

Family Medical History

I am adopted Breast cancer Lung/ respiratory disease None of the above
Unknown Colon cancer Migraines Mother, grandmother or sister developed
Alcohol abuse Depression Osteoporosis heart disease before age of 65

Anemia Diabetes Other canser Father, grandfather, or brother

Anesthetic Heart disease Rectal cancer developed heart disease before the age
complications of 65

Arthritis High blood pressure Seizures/convulsions

Asthma High cholesterol Severe allergy
Bladder problems Kidney disease Stroke/CVA of the brain
Bleeding disease Leukemia Thyroid problems

Social History
Questions Findings
Occupation
Tobacco/ Alcohol

Illicit Drugs

Caffeine use (if applicable)

Diet (especially if on a special diet; or should be on one but

is not)
Exposure (if applicable, such as with infections)

Sexual partners (if applicable)

Living situation

Ability to perform ADLs (if applicable)

Recreation

Safety situations (i.e. abuse; if applicable)

Gordon’s Functional Health Management Pattern
1. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN
a. How was general health been?

b. Any colds in past years? When appropriate: absences

from work?
c. Most important things you do to keep healthy? Think
these things make a difference to health? (Include family
folk remedies when appropriate.) use of cigarettes,
alcohol, drugs? Breast self-examination?
d. Accidents? (home, work, driving)?
e. In past, been easy to find ways to follow suggestion
from physicians or nurses?
f. When appropriate: what do you think caused this
illness? Actions taken when symptoms perceived?
Results of action?
g. when appropriate: things important to you in your
health care? How can be more helpful?
2. NUTRITION METABOLIC PATTERN
1. History
a. Typical daily food intake? (Describe.) Supplements
(vitamins, type of snacks)
b. Typical daily fluid intake? (Describe.)
c. Weight loss or gain? (Amount) Height loss or gain
(Amount)
d. Appetite?
e. Food or eating: Discomfort? Swallowing? Diet
restrictions?
f. Heal well or poorly?
g. Skin problems: Lesions? Dryness?
h. Dental problems
2. Examination
a. Skin: Bony prominences? Lesions? Color changes/
Moistness
b. Oral mucous membranes: Color? Moistness? Lesions?
c. Teeth: General appearance and alignment? Dentures?
Cavities? Missing teeth?
d. Actual weight, height, e. Temperature
e. Intravenous feeding-parenteral feeding (specify)?
3. ELIMINATION PATTERN
1. History
a. Bowel elimination pattern? (Describe) Frequency?
Character? Discomfort? Problem in control? Laxatives?
b. Urinary elimination pattern? (Describe) Frequency?
Problem in control
c. Excessive perspiration? Odor problems?
d. Body cavity drainage, suction, and so on. (Specify)
2. Examination
a. when indicated: examine excreta or drainage color and
consistency
4. ACTIVITY-EXERCISE PLAN
1. History
a. Sufficient energy for desired or required activities
b. Exercise pattern? Type? Regularity?
c. Spare-time (leisure activities? Child: play activities?
d. Perceived ability (code for level) for • Feeding •
Bathing • Toileting • Home Maintenance • Dressing •
Grooming • General Mobility • Cooking • Shopping • Bed
Mobility
2. Examination
a. Demonstrated ability for: • Feeding- • Bathing •
Toileting • Home Maintenance • Dressing • Grooming •
General Mobility • Cooking • Shopping • Bed Mobility
b. Gait • Posture • Absent body part
c. Range of motion (points) • Muscle • Firmness d. Hand
grip?  Can pick up a pencil?
e. Pulse • Rate • Rhythm • Breath sounds f. Respiration
• Rate • Rhythm • Breath sounds
g. Blood Pressure
h. General Appearance (grooming, hygiene, and energy
level)
5. COGNITIVE-PERCEPTUAL PATTERN
1. History
a. Hearing difficulty? Hearing aid?
b. Vision? Wear glasses? Last Checked? When last
changed?
c. Any change in memory lately
d. Important decision easy or difficult to make?
e. Easiest way for you to learn things? Any difficulty?
f. Any discomfort? Pain? When appropriate: how do you
managed it?
2. Examination
a. Orientation
b. Hears whisper
c. Reads newsprint
d. Grasps ideas and questions (abstract, concrete)
e. Language spoken
f. Vocabulary level. Attention span.
6. SLEEP-REST PATTERN
1. History
a. How describe self? Most of the time, feel good (not so
good) about self?
b. Changes in body or things you can’t do? Problem to
you?
c. Changes in the way you feel about yourself or body
(since illness started)?
d. things frequently make you angry? Annoyed? Fearful?
Anxious?
e. Ever feel you lose hope?
2. Examination

a. Eye contact. Attention span (distraction)

b. Voice and speech pattern. Body posture.
c. Nervous (5) or relaxed (1); rate from 1 to 5
d. Assertive (5) or passive (1); rate from 1 to 5
8. ROLES-RELATIONSHIP PATTERN
1. History
a. Live alone? Family? Family structure (diagram)?
b. Any family problems you have difficulty handling
(nuclear or extended)?
c. Family or others depend on you for things? How
managing?
d. When appropriate: How family or others feel about
illness or hospitalization?
e. When appropriate: Problems with children? Difficulty
handling?
f. Belong to social groups? Close friends? Feel lonely
(frequency)?
g. Things generally go well at work? (School)?
h. When appropriate: Income sufficient for needs?
i. Feel part (or isolated in) neighborhood where living?
2. Examination
a. Interaction with family member(s) or others (if
present)
9. SEXUALLY-REPRODUCTIVE PATTERN
1. History
a. When appropriate to age and situation: Sexual
relationship satisfying? Changes? Problems?
b. When appropriate: Use of contraceptives? Problems?
c. Female: When menstruation started? Last
menstruation period? Para? Gravida?
2. Examination
a. None unless problem identified or pelvic examination
is part of full physical assessment.
10. COPING-STRESS TOLERANCE PATTERN
a. Any big changes in your life in the last year or two?
Crisis?
b. Who’s most helpful in taking things over? Available to
you now?
c. Tense or relaxed most of the time? When tense, what
helps?
d. Use any medicines, drugs, alcohol?
e. When (if) have big problems (any problems) in your
life, how do you handle them?
f. Most of the time is this (are these) way(s) successful?
11. VALUES-BELIEFS PATTERN
1. History
a. Generally get things you want from life? Important
plans for the future?
b. Religion important in life? When appropriate: does
this help when difficulties arise?
c. When appropriate: will being here interfere with any
religious practices?
2. Examination: NONE
3. Other concerns a. Any other things we haven’t talked
about that you would like to mention? b. Any questions?

Review of Systems
Findings
General state:
 Usual weight, recent weight change, weakness,
fatigue, fever
Skin
 Texture, growth, color changes, dryness,
sweating, lesions, rashes, itchiness, changes in
nails, hairs, and skin turgor
Eyes
 Inflammation, discharge, blurring, pain, double
vision, vision, use of glasses or contact lenses,
past eye examination, redness, excessive tearing,
glaucoma
Ears
 Hearing difficulties/deafness, tinnitus, vertigo,
earaches, infection, discharge
Nose
 Discharge, obstruction, sense of smell (presence
or absence), nose bleeding, sneezing, frequent
colds, nasal stuffiness, hay-fever, sinusitis
Mouth/ Throat
 Gum infection, soreness of the throat and tongue,
bleeding, hoarseness, difficulty in swallowing,
condition of teeth and gums, dental health
Neck
 Injury, stiffness, lumps, pain, swollen glands, goiter
Chest/ Pulmonary
 Cough, sputum, phlegm, breath sounds, asthma,
hemoptysis, bronchitis, emphysema, pneumonia,
tuberculosis, wheezing, cyanosis, last x-ray seen,
etc.
Breast/ Cardiac
 Heart trouble, high blood pressure, rheumatic
fever, heart murmurs, dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, edema, chest
pain, shortening of breath, cyanosis, palpitations,
past ECG or heart tests.
GI
 Appetite, nausea, vomiting, abdominal pain, rectal
bleeding, black-tarry stools, hemorrhoids,
jaundice, liver or gallbladder trouble, hepatitis,
change in bowel habits, constipation, diarrhea,
food intolerance, flatulence, difficulty in
swallowing, heartburn, indigestion, etc.
Urinary
 Frequency of urination, polyuria, dysuria,
hematuria, urgency, urinary incontinence or
hesitancy, infections, presence of stones, changes
in the color and amount, discharge (blood/pus)
Genito-reproduction:
 Male: discharge from or sores on penis, hernias,
undescended testes, testicular pain or masses
 Female: age of menarche, regularity, frequency
and duration or periods, amount of bleeding,
bleeding between periods, last menstrual period,
amenorrhea, dysmenorrhea, discharges, itchiness
Musculoskeletal
 Joint pains or stiffness, arthritis, gout, backache,
pain, cramps, weakness, numbness, injury,
coldness, etc.

Hematology
 Easy bruising or bleeding, anemia, past
transfusions, possible reactions
Peripheral Vascular
 Intermittent claudication, cramps
 Varicose veins
 Thrombophlebitis
Neurological/ Head
 Seizures, convulsion, loss of consciousness,
sensory changes (pain, tingling, loss of sensation);
mood disturbances (imbalance, tremors,
weakness),
 Emotional status (depression, nervousness,
disturbed, interpersonal relationship, memory
changes, fainting, blackouts, paralysis, local
numbness
Endocrine
 Thyroid problem, temperature (heat or cold)
intolerance, excessive sweating, diabetes mellitus,
excessive thirst, hunger or urination, change in
urinary secondary sex characteristics, excessive
hair growth

Phyical Examination
Findings
Vital Signs Temp:
Time: PR:
BP:
RR:
O2 Sat:
Vital Signs Temp:
Time: PR:
BP:
RR:
O2 Sat: