HEALTH HISTORY

I.

Biographical data:
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
Age: _______Sex: _______ Citizenship: _______________ Religion: ____________________________
Birthdate: _________________ Civil Status: ____________ Nationality: __________________________
Educational Attainment: __________________________ Birthplace: _____________________________
Occupation: __________________________________________________________________________
Health insurance: Philhealth? _____ Yes _____ No
Other health insurance? _____ Yes _____ No
If yes, please indicate: _________________________________________
Information obtained from:
Patient
Others: Name_______________________________________________________________
Relationship: ____________________________________________________________
Reliability of Source: ___________________________________________________________________
Date when the information was obtained: ___________________________________________________

II.

Chief complain and history of present health illness:

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Clinical impression: ____________________________________________________________________
_____________________________________________________________________________________
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III. Past health history

Indicate surgery/ies undergone.
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Indicate hospitalizations and significant illnesses.
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Allergies:
Food? _____ Yes _____ No; If yes, what kind of food? ________________________________
Reactions? ____________________________________________________________________
Medicine/s? _____ Yes _____ No; If yes, name of medicine/s? __________________________
Reactions? ____________________________________________________________________

 Latex? _____ Yes _____ No

Reactions? ____________________________________________________________________
Environment? _____ Yes _____ No; If yes, what kind? ________________________________
Reactions? ____________________________________________________________________
Immunizations:
Has the patient received any recent immunization/s received?
_____________________________________________________________________________
Medication Reconciliation:
Is there any medication currently being taken or are there previous medications that were taken
_____________________________________________________________________________
IV. Family Health History

V.

Cancer _______________________________________________________________________
Tuberculosis __________________________________________________________________
Hypertension __________________________________________________________________
Diabetes Mellitus _______________________________________________________________
Others _______________________________________________________________________

Psychosocial History
A. Past events related to health
Places where the patient lived: ____________________________________________________________
Significant childhood/adolescent experiences: _______________________________________________
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B. Education and occupation
Jobs held in the past: ___________________________________________________________________
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Current position or job: _________________________________________________________________
Length of time at position: _______________________________________________________________
Work satisfaction and career goals: ________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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C. Lifestyle Patterns:
Exercise
Type: __________________ Frequency: _________________ Time spent: _________________
Sleep
Usual time: _________________________________
Duration: ________________________________
Bedtime Rituals: ________________________________________________________________
Any sleep interruption/s? _____ Yes _____ No
If yes, are there remedies done? ____________________________________________________
Recreation

Type of activity: ________________ Frequency: ______________ Time spent: ______________

Nutrition (24-hour diet recall)
Breakfast: _____________________________________________________________________
Lunch: ________________________________________________________________________
Supper: _______________________________________________________________________
Snacks: _______________________________________________________________________
Dietary restrictions: ______________________________________________________________
Food idiosyncrasies: _____________________________________________________________
Caffeine: _____ coffee _____tea _____chocolate _____soda/cola
Amount: __________ Frequency: ___________
Tobacco Use: _____ Yes _____ No. If yes, how long? _________
How much? _____ packs/day _____sticks/day
Kind? _________________________________________________________________________
Desire to quit? _____ Yes _____ No If No, Why? _____________________________________
Alcohol Use: _____ Yes _____ No. If yes, how long? _________
How much? ________ per day ________ per week
Kind? _________________________________________________________________________
Desire to quit? _____ Yes _____ No If No, Why? _____________________________________
Illicit Drug use: _____ Yes _____ No. If Yes, how long? _________
How much? _______ per day _______ per week
Kind? _________________________________________________________________________
Route of administration? __________________________________________________________
Desire to quit? _____ Yes _____ No If No, Why? _____________________________________
Sexually active: _____ Yes ____ No
Any sexually transmitted disease? _____ Yes _____ No
If yes, indicate what kind ________________________________________________________________

D. Self concept:
View of self in the present: ______________________________________________________________
View of self in the future: _______________________________________________________________
Body image (level of satisfaction, concerns): ________________________________________________
_____________________________________________________________________________________
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E. Physical or mental disability:
Presence of disability (Physical/Mental):____________________________________________________
Effects of disability on function/ADLs: _____________________________________________________
Accommodations needed to support functioning: _____________________________________________
F. Risk for abuse:
Physical injury in the past: _______________________________________________________________
Any fear of partner or family member: _____________________________________________________
G. Stress and Coping Mechanisms:
Major concerns or problems at present: _____________________________________________________
Daily hassles: _______________________________________________________________________
Past coping patterns and outcomes: ________________________________________________________

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Present coping strategies and anticipated outcomes: ___________________________________________
_____________________________________________________________________________________
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Individuals expectation of family/friends and health care team in problem resolution: _______________
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H. Environment
Physical
Living arrangements
Type of housing: ________________________________________________________________
Presence of hazards: _____________________________________________________________
Spiritual:
Religious beliefs and practices related to health and illness: ______________________________
______________________________________________________________________________
______________________________________________________________________________
Interpersonal:
Ethnic background: ______________________________________________________________
Language/s spoken: ______________________________________________________________
Folk practices used to maintain health or to cure illness: _________________________________
______________________________________________________________________________
Family relationships
Family structure: ________________________________________________________________
Roles: ________________________________________________________________________
Communication patterns: _________________________________________________________
Support system: ________________________________________________________________
VI. Functional assessment
FIM scoring
Patients name: ________________________________________________________________________
Patients birthday: _____________________________________________________________________
Hospital ID or registration number: ________________________ Dept./Unit: ______________________
Chief complaint and diagnosis: ___________________________________________________________
7 = independent; no use of assistive devices
6= modified independence; use of assistive devices independently
5 = supervision only; no actual physical contact/ touching of patient
4 = minimal assistance; 25% assistance from staff to complete activity;
75% actual performance by patient
3 = moderate assistance; 50% assistance from staff to complete activity;
50% actual performance by patient
2 = maximal assistance; 75% assistance from staff to complete activity;
25% actual performance by patient
1 = totally dependent; more than 75% assistance from staff to complete activity;
Less than 25% actual performance by the patient

Areas
Grooming

Scores

Dressing UE (upper extremity)

Dressing LE (lower extremity)
Toileting/ elimination
Feeding/ eating