Fhp Template

STUDENT NURSE(S): College of Nursing Foundation University Dumaguete City

I. DEMOGRAPHIC DATA Name of Patient: _______________________________________________ Room & Bed: _______ Date & Time of Admission: ___________________ Sex: ____ Age: ____ Religion: __________________ Marital Status: ______ Educational Attainment: _____________________ Address: _____________________________________________________________________________ Nationality: ___________ Doctor(s) in Charge: ___________________________________________________________________

II. Chief Complaints/ Reason for Seeking Medical Care:

III.

History of Present Illness:

IV.

General Impression:

FUNCTIONAL HEALTH PATTERN USUAL HEALTH PATTERN A. HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN

INITIAL APPRAISAL ( )

ONGOING APPRAISAL ( )

B. NUTRITIONAL- METABLOIC PATTERN

C. ELIMINATION PATTERN

D. ACTIVITY- EXERCISE PATTERN

E. SLEEP- REST PATTERN

F. COGNITIVE-PERCEPTUAL PATTERN

G. SELF-PERCEPTION- SELF-CONCEPT PATTERN

H. ROLE- RELATIONSHIP PATTERN

I. SEXUALITY- REPRODUCTIVE PATTERN

J. COPING- STRESS TOLERANCE PATTERN

K. VALUE- BELIEF PATTERN