BIOGRAPHIC DATA Name: Address: Age: Gender: Religious Affiliation: Occupation: Civil Status: Room and Bed no.

: Chief Complaint: Provisional Diagnosis: Attending Physician: Brief History (paragraph): Name, Age, Citizenship, Address, Reason for coming to hospital,/ Reason for transfer [last hospital/clinic addmitted], Clinical diagn osis NURSING HISTORY PAST HEALTH HISTORY: Childhood history of illness, Immunization, hospital admiss ion date and reason (from 5 years ago), history of accident or injury, food/drug allergy HISTORY OF PRESENT ILLNESS: Reason for coming to hospital, date of manifestation , day of admission, brief history before experiencing manifestation, location or place before admission, activities before manifestation FAMILY HEALTH HISTORY: Hereditary disease (diabetes, HPTN, Cancer, and the likes ) GENOGRAM Name, age, family tree, living, dead [date of death], sickness, well PATTERNS OF FUNCTIONING PSYCHOLOGICAL HEALTH: COPING PATTERN: To you what is your perception of stressful events?, Ways/source of coping [higher being, family, work/hobby], What do you do to cope?, what do you do with problems to minimize it? [physical, financial, emotional], How do yo u cope by yourself without others? INTERACTION PATTERN: How well do you interact with others when happy, angry, etc ? How do you show anger, loneliness, etc? COGNITIVE PATTERN: Educational Attainment, Able to read and write, understand or speak [english, tagalog or other dialect], own perception of health and well-being SELF-CONCEPT: How do you see life?, Describe Yourself, Rate own Health Status [1 lowest/10 peak][ex. Reason why 7?], Tolerance to pain [Pain Scale], Where do yo u experience pain in/on your body? EMOTIONAL PATTERN: Common Mood? or Moody?, Common problems?, Source of happiness SEXUALITY PATTERN: Expression of being [woman, mother, grandmother, man, father, grandfather, etc], Sexualy Active?, How well/clean are you with your physical s exuality? FAMILY COPING: To you what is family? Who do you consult 1st during family hards hips?, Who do you share it with after if needed assistance?, Who is your last re sort?

SOCIO-CULTURAL PATTERN: CULTURAL PATTERN: Province, Ethnicity, Current Address (length of stay), Primary dialect used (in home, in work, in school), How often do you visit your provinc e? What is/are the common culture of the said ethnicity? SIGNIFICANT RELATIONSHIP: Who were the well versed people to you?, Do you connec t with them in times of need?, How does your family attend to life's trials? RECREATION PATTERN: What do you do to release stress? What do you do during holi days/special days? ENVIRONMENT: Identification of house (estimation, ventilation, cleanliness), Ide ntification of community (cleanliness, close to bin, close to streams, close to what?), How do you dispose your garbage?, Water source for cleaning?, Water sour ce for drinking and cooking?, lighting?, Who were the people you live with ECONOMIC: Work, where do you work, what kind of work, Sources of income?(others? ), Where do you spend most of your/family's income?, Where do you spend least?, What are your families bills? SPIRITUAL PATTERN: RELIGIOUS BELIEF and PRACTICES: Who/what to you is a higher being?, How often do you go to church?, Means of connection with higher being? VALUES and VALUING: What is the meaning of values for you?, Who are the people m ost valuable to you? ACTIVITIES OF DAILY LIVING: NUTRITION: [BEFORE CONFINEMENT] how many times do you eat a day?, common foods you eat?, amount, favorite (meat, vegetable, drink), favorite recipe? [DURING CONFINEMENT] 3day diet recall ELIMINATION: [BEFORE CONFINEMENT] how many times (urinate, defecate), color of stool and urine?, odor of stool and urine?, identify consistency of stool, can you fee l pain during or before, urinating and defecating(type of pain?)?, amount (estim ate)? [DURING CONFINEMENT] how many times (urinate, defecate), color of stool and urine?, odor of stool and urine?, identify consistency of stool, can you fee l pain during or before, urinating and defecating(type of pain?)?, amount (estim ate)? EXERCISE: [BEFORE CONFINEMENT] Common activities, do you exercise? (how often?, wh at kind of exercises?) [DURING CONFINEMENT] Common activities, do you exercise? (how often?, wh at kind of exercises?) HYGIENE: [BEFORE CONFINEMENT] How often do you take a bath?, how often do you cha nge clothes? How often do you trim your nails? [for female: do you use feminine wash for your feminine hygiene?] [DURING CONFINEMENT] How often do you take a bath or do you do sponge ba th and how often?, how often do you change your clothes and bed linen?, How ofte n do you trim your nails? SUBSTANCE USE: [BEFORE CONFINEMENT] Do you use drugs before like vitamin C, stress tabs

, etc? How often and when? [consider weigh gain, steroids, calciaid and the like s] [DURING CONFIENMENT] DRUG STUDY, do you have any supplements other than the drugs prescribed by your doctor? SLEEP and REST: [BEFORE CONFINEMENT] Usual time of sleep, time of wake-up, you sleep?, how many hours do you sleep per day (estimate), how do r waking-up? Do you have any sleep rituals? [DRUING CONFINEMENT] Usual time of sleep, time of wake-up, you sleep?, how many hours do you sleep per day (estimate), how do r waking-up? What are the things that makes you loose your sleep? SEXUAL ACTIVITY: [BEFORE CONFINEMENT] [DURING CONFINEMENT] how often do you feel afte how often do you feel afte