Demographic Data & Health History

MINDANAO STATE UNIVERSITY Iligan Institute of Technology DEPARTMENT OF HEALTH SCIENCES NURSING HEALTH ASSESSMENT Student Name______________________________ Area of Assignment:______________________________

Date of Care ___________

DEMOGRAPHIC DATA Name: Address: Age: Sex: Status: Religion: Occupation: HEALTH HISTORY A. Chief Complaint/s: B. Impression/Admitting Diagnosis: C. History of Present Illness: (Location, onset, character, intensity, duration, aggravation and alleviation, associated symptoms, previous treatment and result, social and vocational responsibilities)

D. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illness, allergies, medication, habits, birth and development history, nutrition – for pedia)

E. Health Habits Frequency

Amount

Period

Tobacco Alcohol OTC drugs/non-prescription drugs Specify: F. Family History with Genogram History of Heredo-familial diseases: Cancer _____ DM _____ Asthma _____ Hypertension _____ Cardiac Disease _____ Mental Disorder _____ Others _____ G. Patient’s Perception of Present Illness: Hospital Environment: H. Summary of Interaction

Genogram