COMPREHENSIVE HEALTH ASSESSMENT
Name of Patient:
Impression/ Diagnosis:
Physician:
Age:
Sex:
Civil Status:
Date of Admission:
Room No.:
Date of Assessment:
Attending
I. HEALTH HISTORY
Chief Complaint:
Present health status:
Past health history:
Current Lifestyle:
Psychosocial status:
Family history:
Gynecologic history (if applicable):
Menstrual History (Usual Cycle) Interval:
Flow:
Last Menstrual Period and LMP:
Expected Date of Delivery
Duration:
Amount of Menstrual
EDD:
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History of Dysmenorrhea? [ ] Yes [ ] No Gynecologic surgeries? [ ] No [ ] Yes; pls.
specify:
Obstetric history (if applicable):
Pregnancy Profile (GPTAL) Gravity:
Term:
Preterm:
Abortions:
Living Children:
Previous Pregnancies? [ ] No [ ] Yes; Please specify in chronological order):
Date: Name of Child Type of Delivery Outcome
II. PHYSICAL EXAMINATION
A. PRELIMINARIES
VITAL SIGNS AND ANTHROPOMETRIC MEASUREMENTS
Blood pressure:
Height:
Heart rate:
Weight:
Pulse Rate:
BMI:
Temperature:
[ ] within ideal body weight (IBW) Respiratory Rate:
[ ] less than IBW
Others:
[ ] more than IBW; specify:
GENERAL SURVEY:
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E. CARDIOPULMONARY
HEART & VASCULAR
Auscultated heart sounds:
Apical pulse (rate & rhythm):
Jugular venous distention: [ ] present [ ] absent Capillary
refill: [ ] > 1 second [ ] < 2 seconds [ ] PMI palpable – 5thintercostal space medial to left
midclavicular line [ ] PMI not palpable [ ] edema (describe):
Blood Pressure:
MAP:
[ ] Pulse Deficit:
Peripheral Pulses:
Comments:
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SUMMARY OF SIGNIFICANT FINDINGS (Narrative):
NURSING DIAGNOSES
1.
2.
3
Assessment done by:
Signature over Printed Name of Student
II.FOCUSED PHYSICAL ASSESSMENT [Should be completed on the 2nd and 3rd day]
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System Assessed: [ ] Integument [] Head & Neck [ ] Eyes & Ears [ ]Cardiopulmonary [ ]
Preliminaries [ ] Gastrointestinal [ ] Genitourinary/OB [ ] Musculoskeletal [ ] Neurologic
Inspection
Palpation
Percussion
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Auscultation
Other significant findings:
Nursing Diagnosis:
Assessment done by:
Signature over Printed Name of Student
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