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HEALTH HISTORY
Biographic Data Name:_____________________________________Gender:____Age:___Marital status:______ Birthday:_________ Birthplace:___________________________ ___Religion:______________ Address:___________________________________Nationality:___________Citizenship:_____ Occupation:___________________ Health Care Resources:____________ Chief Complaint a. What is troubling?
f. Kindly specify to me the parts of your body that are being affected?
g. If you rate the pain you experienced from 1 to 10, what number would it corresponds? h. Are there things that when you do such, the pain was being aggravated or alleviated?
Past Health History a. Have you encountered childhood illnesses? Can you specify them?
b. Did you receive any vaccines in your childhood? Cite some of those.
c. Did you have any allergies on food, drugs, animals, or other environmental agents? If so, what is the type of reaction that occurs?
d. When did the last time you encountered an accident/injury? When did it happen? What part of your body was affected? What kind of accident or injury was it? What is the treatment you received?
e. Have you been hospitalized before? Where hospital have you been confined? What is the name of the hospital? What is the reason for hospitalization?
f. Have you undergone any surgical procedure/operations? If so, what are these?
Family Health History a. What genetically linked or common diseases that runs in your family?
Name:_____________________________________Gender:____Age:___Marital status:______ Birthday:_________ Birthplace:___________________________ ___Religion:______________ Address:___________________________________Nationality:___________Citizenship:_____ Occupation:___________________ Health Care Resources:____________
c. What are the different ways you perform to maintain proper hygiene? Do you take a bath every day? How many times you brush your teeth?
d. What do you usually do when you're sick? Do you take over-the-counter medications? Do you take medications which are not prescribed from any physicians?
Nutritional-Metabolic Pattern Height:_________ Weight:________ a. How many times you eat daily? What is your regular meal? How many cup of rice?
e. Do you have any allergy? If so, what type of reaction that occurs?
Elimination Pattern a. How many times you urinate every day? Do you feel any pain on your urination? Kindly describe to me the color of your urine?
b. How many times you defecate in a week? Kindly describe to me the color of your stool? Is it hard or soft?
c. Are you performing exercises or any sort of it? What are those? How often do you exercise?
d. Do you get up at night to go to the bathroom? e. What time do you sleep at night? f. What time do you wake up in the morning? g. Are you taking sleeping pills?
Cognitive-Perceptual Pattern a. Are you having a monthly check up with your different senses? b. Can you see things clearly? c. Are you nearsighted/farsighted? d. How long are you using your eyeglasses/contact lenses, since when? e. Do you hear things clearly? f. Can you distinguish one smell from another? g. Can you decipher the four different tastes?(sweet, bitter ,salty sour) h. Do you have difficulties in remembering things, where do you put that thing?
i. Which do you prefer most of the time, to be alone or to be with many people? Why?
Role-Relationship Pattern a. How is your relationship with your family? (to your brothers, sisters, parents)
Sexuality-Reproductive Pattern a. Do you have any problem with your reproductive system?
b. Are you married? If yes, how often do you have sexual intercourse?
d. Do you have a regular menstrual period? e. During those times, are you having a dysmenorrhea ? What do you usually do to relieve the pain?
f. If you are single ,what do you usually do to satisfy your needs as a male?
Coping-Stress Tolerance Pattern a. What do you do when you feel stressed? Do you eat too much, take a nap, cry, hit yourself or what?
b. Are you fund of attending 'gimiks' or any recreational activities? What are those? Does it help you feel relieved?
c. Are there any superstitious beliefs you usually do related to health? What are these?
d. In your religion, are there medical practices which are not allowed?