HEALTH ASSESSMENT
(HEALTH HISTORY AND PHYSICAL EXAMINATION)
A. Demographic (Biographical Data)
1. Client’s initial
2. Gender
3. Age, Birthdate and Birthplace
4. Marital (Civil) Status
5. Nationality
6. Religion
7. Address and Telephone Number
8. Educational Background
9. Occupation (usual and present)
10. Usual Source of Medical Care
11. Date of Admission
B. Source and Reliability of Information
 Should be in narrative form (describe specifically according to the patient’s
manifestation or capability)
Sample Statements:
The patient was competent to provide information. She was able to speak clearly;
conscious and coherent; oriented to time, place and person.
Other Possibilities:
The patient was too weak to provide information; data had to be obtained and
validated from the relative.
...information provided were comprehensive and reliable (or limited)
...able to articulate clearly
C. Reasons for Seeking Care or Chief Complaints (Preferably Top 3)
Sample Statements:
“Chest pain for 2 hours”
“Earache and restlessness all night”
“Physical examination for work purposes”
“Wants to start jogging and needs check-up”
D. History of Present Illness or Present Health
Well person
General state of health
Ill person
Chronological story record
8 Critical Characteristics: (in narrative form)
1. Timing (frequency/onset/duration)
2. Location (the primary area where the symptom occurs or originates)
3. Quality (Character) – (describes the way the cc feels to the patient)
4. Quantity / Severity (volume, number, or extent of the cc)
5. Setting (physical environment, mental state, or activity wherein the symptoms occur)
6. Associated Phenomena / Factors (signs and symptoms that accompany the cc)
7. Aggravating and Alleviating Factors (factors that worsen or decrease the
severity of the cc, respectively)
8. Client’s Perception (how the client thinks & feels about the illness)
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Example:
Patient was in a usual state of good health until one week ago; at that time, he had
SOB with tightness in the chest and mild wheezing; he has been using albuterol MDI
2 inhalations qid, which usually makes breathing easier; no other medications taken;
patient usually runs 5 miles daily and he has not felt up to running the past week;
describes SOB; temperature of 370C yesterday; (+) sore throat; (+) fatigue, denies
sputum, cough, sinus pressure, tooth pain, nasal discharge, nasal polyps; noticed
that symptoms started the day before he did yard work before the recent storm; had
2 feet of water in the basement of their house; had cleared tree debris at the
backyard from wind damage; patient reports that he and his wife rescued a stray cat
2 weeks ago and the cat now lives in the house and often sleeps on his bed; patient
is concerned because he has not felt this ill in many years; he also recently started a
new job and does not want to miss time at work due to illness.
E. Past Medical History or Past Health
a. Pediatric / Childhood / Adult Illnesses
b. Injuries or Accidents
c. Hospitalization and Operations
d. Reproductive History (for females – include menstrual history (age at menarche,
LMP, cycle and duration), also include OB history (if pregnant: OB score),
complications of pregnancy and birth control methods used)
e. Immunization
BCG: / / At Birth
/ / School Entrance
st
DPT: / / 1 Dose
/ / 2nd dose
/ /3rd dose
OPV: / / 1st Dose
/ / 2nd dose
/ /3 rd dose
AMV: / /
TT:
/ / 1st Dose / / 2nd dose
/ /3rd dose
/ / 4th dose
/ / 5th dose
HBV: / / 1st Dose
/ / 2nd dose
/ /3 rd dose
Others: (Varicella Vaccine, Influenza Vaccine, Pneumococcal Vaccine etc.)
f. Allergies
/ / foods, please specify: _________________________
/ / Drugs or medications, please specify: ________________________
/ / Chemicals, please specify: _________________________
/ / Other environmental allergens, please specify: _________________________
g. Medications – include all current and past medications taken, both prescription
and over the counter
F. Family History
(With GENOGRAM / Family Tree; with brief explanation of significant data)
(Include age, present condition, cause of death)
Use the following legend:
Male
Female
Patient
Deceased
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G. Socio-Economic History
(Include a brief explanation of significant data)
(Include income earners in the family only)
FAMILY MEMBER
OCCUPATION /
SOURCE OF INCOME
MONTHLY INCOME
(optional)
H. Psychosocial Assessment
(Specific for the current developmental stage of the client)
(Use Erik Erikson’s Psychosocial Development Theory)
I. Functional Assessment
(Use Gordon’s Functional Health Pattern)
1. Health-Perception-Health Management Pattern
2. Nutritional-Metabolic Pattern
3. Elimination Pattern
4. Activity-Exercise Pattern
5. Sleep-Rest Pattern
6. Cognitive-Perceptual Pattern
7. Self-Perception-Self Concept Pattern
8. Role Relationship Pattern
9. Sexuality-Reproductive Pattern
10. Coping-Stress Tolerance Pattern
11. Value-Belief Pattern
J. Review of Systems and Physical Examination
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SYSTEM
General
Integument
Head
Eyes
Ears
Nose and Sinuses
Mouth and Throat
Neck
Breast and Axilla
Respiratory
Cardiac
Gastrointestinal
Urinary
Genitalia
Peripheral Vascular
Musculoskeletal
Neurologic
Hematologic
Endocrine
Psychiatric
R.O.S.
P.E.
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FUNCTIONAL ASSESSMENT
(Interview Guide)
1. Health-Perception-Health Management Pattern
 Describes the client’s perceived patterns of health & well- being & how their health is
managed.
person’s description of his current health
activities that the person does to improve or maintain his health
person’s knowledge about links between lifestyle choices and health
extent of person’s problem on financing health care, if any
person’s knowledge of the names of current medications he is taking and their
purpose/s
 activities that the person does to prevent problems related to allergies, if any
 person’s knowledge about medical problems in the family
 any important illnesses or injuries in this person’s life
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2. Nutritional-Metabolic Pattern
 Describes the consumption relative to metabolic need & nutrient supply; includes
pattern of food & fluid consumption, condition of skin, hair, nails & mucous
membranes, body temperature, height & weight.
 person’s nourishment
 person’s food choices in comparison with recommended food intake
 any disease that affects nutritional-metabolic function
3. Elimination Pattern
 Describes the pattern of excretory function (bowel, bladder & skin); includes
individual’s daily pattern, changes or disturbances & methods used to control
excretion.
 person’s excretory pattern
 any disease of the digestive system, urinary system or skin
4. Activity-Exercise Pattern
 Describes the pattern of exercise, activity, leisure, & recreation; includes activities of
daily living, type and quality of exercise & factors affecting activity pattern (such as
neuromuscular, respiratory, & circulatory).
 person’s description of his weekly pattern of activities, leisure, exercise and
recreation
 any disease that affects his cardio-respiratory and/or musculoskeletal systems
5. Sleep-Rest Pattern
 Describes the pattern of sleep, rest & relaxation and any aids to change those
patterns.
 description of the person’s sleep-wake cycle
 person’s physical appearance (rested or relaxed?)
6. Cognitive-Perceptual Pattern
 Describes the sensory-perceptual and cognitive patterns; includes adequacy of
sensory modes (vision, hearing, touch, taste and smell), reports of pain perception,
and cognitive functional abilities.
 any sensory deficit and if corrected
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person’s ability to express himself clearly and logically
person’s education
any disease that affects mental or sensory function
person’s pain description & causes, if any
7. Self-Perception-Self Concept Pattern
 Describes how persons perceive themselves; their capabilities, body image and
feelings.
 anything unusual about the person’s appearance (based on his own description)
 if person is comfortable with his appearance
 description of the person’s feeling state
8. Role Relationship Pattern
 Describes the pattern of role engagements and relationships; includes perception of
major roles & responsibilities in current life situation.
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person’s description of his various roles in life
positive role models of his roles, if any
important relationships at present
any big changes in role or relationship
9. Sexuality-Reproductive Pattern
 Describes the pattern of satisfaction or dissatisfaction with sexuality; includes
female’s reproductive state.
 person’s satisfaction with his situation related to sexuality
 How have the person’s plans and experiences matched regarding having
children?
 any disease/dysfunction of the reproductive system
10. Coping-Stress Tolerance Pattern
 Describes the general coping pattern and effectiveness of coping skills in stress
tolerance.
 person’s means/actions of coping with problems
 if coping actions help or make things worse
 any treatment/therapy for emotional distress (if any)
11. Value-Belief Pattern
 Describes the pattern of values, goals, or beliefs (including spiritual beliefs) that
guide lifestyle choices and decisions.
 principles that the person learned as a child which are still important to him
 person’s identification with any cultural, ethnic, religious, regional or other
groups
 support systems that the person finds significant
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REVIEW OF SYSTEMS
(A Guide)
Note: Some symptom/s findings may appear in more than one system, answers only need to be
recorded once
GENERAL:
Present weight (gain, loss, period of time, by diet or other factors), fatigue, weakness or malaise,
fevel, chill, sweats or night sweats
INTEGUMENT:
Skin: History of skin disease (eczema, psoriasis, hives, pigment or color change in mole, excessive
dryness or moisture pruritus, excessive bruising, rashes or lesions, include amount of sun exposure
and method of self-care)
Hair: Recent loss, changes in texture
Nails: Change in shape, color, or brittleness
HEAD:
Any unusual frequent or severe headache, any head injury, dizziness, vertigo
EYES:
Changes in vision, use of glasses or contact lenses (When was it first used and for how long?), eye
pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights,
glaucoma, cataracts and last eye examination
EARS:
Otorrhea, tinnitus, history of infections, vertigo, ear pain, hearing loss and how it affects life,
hearing aid use, any exposure to environmental noise and method of cleaning ears
NOSE AND SINUSES:
Frequent colds, nasal stuffiness, discharge or itching, nosebleeds, sinus trouble
MOUTH AND THROAT:
Mouth pain, frequent sore throat, bleeding gums, toothache lesion on lips/tongue or mucosa,
dysphagia, hoarseness, or voice change, tonsillectomy, altered taste, pattern of daily dental care,
use of prosthesis (dentures), and last dental check-up
NECK:
Pain, stiffness, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter
BREAST AND AXILLA:
Pain, lump, nipple-discharge, rash, history of breast disease, any surgery of the breast,
performance of BSE including its frequency and method used
RESPIRATORY:
History of lung disease (emphysema, pneumonia, asthma, bronchitis, TB, etc.), chest pain upon
breathing, wheezing, noisy breathing, cough, sputum (color, amount), hemoptysis, toxin or
pollution exposure as well as last CXR study
CARDIAC:
Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of
exertion: ex. walking one flight of stairs, walking from chair to bath, or just talking), orthopnea,
paroxysmal nocturnal dyspnea, edema, history of heart murmur, hypertension, cardiovascular
diseases, anemia, and date of last ECG or other heart tests.
GASTROINTESTINAL:
Appetite, food intolerance, dysphagia, indigestion, other abdominal pain, pyrosis, nausea and
vomiting (character), hematemesis, history of abdominal disease (ulcer, liver, gallbladder,
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jaundice, appendicitis, colitis, flatulence, bowel frequency, any present changes, stool
characteristics, constipation, diarrhea, black-tarry stolls, rectal bleeding, rectal conditions
(hemorrhoids, fistula), use of antacids and laxatives, also include diet history and substance use
URINARY:
Frequency, urgency, nocturia, dysuria, polyuria or oliguria, hesitancy or straining, narrowed
stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease
(kidney disease, kidney stones, UTI, prostate), pain in the flank, groin, suprapubic region, or low
back, also include exercise after childbirth
GENITALIA:
Male: Penis or testicular exam, pain, sore or lesions, penile discharge, lumps, hernia
Female: Any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual
spotting, vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or
symptoms, post menstrual bleeding, last gynecological check-up, last papanicolau smear, also
include OB history (if married: OB score), complications of pregnancy, birth control methods used
and operations undergone
PERIPHERAL VASCULAR:
Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration of hands or
feet (bluish, reddish, pallor, mottling, association with position, especially around feet and ankles),
varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers
Does the occupation of the client involve long-term sitting or standing? Does the client avoid
crossing legs at the knees? Does the client wear support hose?
MUSCULOSKELETAL:
Joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, noise
with joint motion
Muscles: Pain, cramps, weakness, gait problems or problems with coordinated activities
Back: Pain (location and radiation to extremities) stiffness, limitation of motion, or history of back
pain or disease
NEUROLOGIC:
History of seizure disorder and stroke
Sensory function: Memory disorders (recent or distant, disorientation)
Motor function: tics or tremors, paresis – weakness, fainting, blackouts
HEMATOLOGIC:
Bleeding tendency of the skin or mucous membranes, excessive bruising, exposure to toxic agents
or radiation, blood transfusions, and reactions
ENDOCRINE:
History of diabetic symptom (polydipsia, polyphagia, polyuria) history of thyroid disease,
intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, abnormal
hair distribution, nervousness, tremors, and need for hormone therapy
PSYCHIATRIC:
Nervousness, mood change, depression, history of mental dysfunction or hallucinations
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