IMMUNE SYSTEM ASSESSMENT
IDENTIFICATION DATA

Name of patient

Age

Sex

Bed no/ Ward

Ip No

Diagnosis

Date of assessment
HEALTH HISTORY
A. Childhood diseases (Congenital, Communicable and non-communicable diseases)
B. Immunizations- Child-hood vaccinations, Recent vaccinations
C. Recent patient exposure to any infections (Exposure dates)
D. Recent history of unexplained weight loss
E. Exposure to sexually transmitted diseases and blood-borne pathogens (if yes,
treatment taken)*
F. Any multiple persistent infections, fevers of unknown origin, lesions or sores, or any
type of drainage
G. Allergy (pollens, dust, fur, plants, cosmetics, food, medications, vaccines)
The symptoms experienced, and seasonal variations in occurrence or severity.
H. Any past and present medications
I. Surgery if any (Date of Surgery)
J. Blood transfusions if undergone
K. Any autoimmune disorders (Lupus erythematous, Rheumatoid arthritis, Psoriasis,
GBS or any other).
(If any, onset, severity, remissions and exacerbations, functional limitations,
treatments)*
L. Any history of cancer (Type of cancer and date of diagnosis, treatments that the
patient has received or is currently receiving)*
M. Chronic illnesses (Diabetes mellitus, Renal disease, or Chronic obstructive pulmonary
disease)
N. Use of herbal agents and over-the-counter medications
O. History of deworming and prophylactic chemotherapy for filariasis
P. Any history of smoking & alcohol consumption
Q. Dietary pattern and nutritional status
R. Amount of perceived stress and relaxation strategies used
S. Any history of injection drug use or unsafe sexual practices*
T. Occupational or residential exposure to radiation or pollutants
U. Any history of burns or trauma
V. Family history of Cancer, autoimmune disorders, chronic illness
PHYSICAL EXAMINATION
1. Vital parameters

Temperature:

Pulse:

Respiration:

Blood Pressure:

SPO2:

Pain:
2. Anthropometric Measurements

Height:

Weight:

BMI:
3. Integumentary System

Rashes

Lesions (macules, vesicles, pustules)

Dermatitis

Purpura (Subcutaneous Bleeding)

Urticaria

Inflammation

Edema

Any Discharge

Discolouration

Photosensitivity

Patchy hair loss

Pressure ulcers
4. Lymphatic system

Lymph node enlargement
(Anterior and posterior cervical, axillary, and inguinal lymph nodes)

Lymphedema
5. Neurosensory System

Cognitive dysfunction

Fatigue / Lethargy

Hearing loss

Visual changes

Dry eyes

Headache and migraine

Paresthesia

Ataxia

Tetany

Facial paresis/ palsy
6. Respiratory system

Changes in respiratory rate

Cough (Dry or productive)

Increased secretions

Rhinitis

Abnormal lung sounds

Hyperventilation

Bronchospasm/Chest tightness
7. Cardiovascular system

Tachycardia

Hypotension

Dysrhythmia

Anemia/ Pallor

Varicose veins/ Vasculitis
8. Gastrointestinal System

Vomiting

Diarrhea/ Constipation

Abdominal bloating and pain

Hepatosplenomegaly
9. Genitourinary system

Increased Frequency & Urgency

Burning micturition

Hematuria

Genital warts/ Ulceration/ Discharge

Frequent urinary tract infections (UTI)

Pelvic or groin area pain
10. Musculoskeletal System

Joint Pain

Stiffness of joints

Skeletal deformities
NB: Correlate with blood parameters viz ESR, CBC, Vit D and HbsAg And HIV results.
*Refer case file for details.