Activity C INTERVIEWING AND RECORDING ASSESSMENT FINDINGS

Instructions: Use the following Nursing Interview Guide to Interview and record
your subjective findings for a health history of a lab partner, peer, or client.
Your instructor may ask you to turn this in to be evaluated.
Nursing Interview Guide to Collect Subjective Data From the Client
Questions Findings
Biographical Data
Name I'm Severina Capitulo Bais
Gender Babae (Female)
Address, phone number Latondan St, Purok 7, Block 5, Brgy.
Saguin, CSFP
09391605096
Date and place of birth November 18, 1948, sa may Manila
Nationality or ethnicity Filipino
Marital status Married for 50 years
Religious or spiritual practices Catholic
Primary and secondary languages Kapampangan, Tagalog
spoken, written, and read; birth language
Educational level High School Graduate
Occupation and working status Retired, nagtatahi ako ng uniform dati.
Who lives with the client? Identify Sina tita mo, lolo mo, pati pinsan mo
significant others (Ediper).
Caregivers and support people to the Si tito mo, si tita mo.
client
Reasons for Seeking Health Care
1. What is major health care or Heart Problem, una naging sakit ko,
concern? nagkaroon ako ng heart block, kaya
nagkaroon ako ng pace maker.
Naoperahan rin ako sa matres (Myoma),
tapos breast cancer (Stage 1), atsaka
Goiter (benign).
2. Are you comfortable with seeking Oo hmmm, komportable nako.
care from this organization? Past
experiences good or not?
History of Present Health Concern
(use COLDSPA when appropriate)
1. Character of symptom or condition Ngayon, nagkaroon ako Breast Cancer,
tinanggal ano ko (right breast).
Nagkaroon rin ako ng Goiter, pero benign
siya.
2. Onset (when did it begin; better? Nag palpitate ako, tapos mag pacheck up
worse? Same?) ako yung heartbeat ko kurenta (40) na
lang. Diba yung heartbeat na normal 72?
Mababa na lang. (Heart Problem)
Yung sa dibdib ko naman, nung una
 maliit lang bukol nakapa ko, tapos
hinayaan ko, hanggang sa lumaki siya,
tapos ayun pinatanggal na ng doctor
cancerous na pala. (Breast Cancer)
3. Location (where and does it 1992, dito sa atin (Latondan St, Purok 7,
radiate?) Block 5, Brgy. Saguin, CSFP) pumutok
non pinatubo doon nagumpisa. (Heart
Problem, pace maker)
4. Severity (on scale of 1 – 10?) Noon, sa puso ko, normal (5) naman kasi
agad na lagyan ako pace maker, pero
ngayon dinadamdam ko yung pagkaalis
ng breast ko, kasi hanggang kili kili
masikip sa pakiramdam.
5. Pattern (what makes it better? Tapos nag pacheck up ako sa heart
worse?) center, nirepair ako doon tapos nanghina
ako, katapos nilagay pace maker ko,
bumalik na lakas ko.
6. Associated factors (other Sa hagdan, di ako makaakyat agad,
associated symptoms? Effect madaling mapagod.
on leisure or exercise?)
Past Health History
Problems at birth? Wala.
Childhood illnesses? Nagkaroon ako ng Nasal Polyps, nung
dalaga ako, inalis yung Polyps, malilit na
bukol inalis, di opera. Sinungkit lang.

Immunizations to date? Oo, sa school noon.

Acute or chronic adult illnesses (physical, Kung chronic matagal na ganun, ito sa
emotional, mental)? puso ko, nagmamaintenance rin ako dito.
Surgeries? Heart pace maker, breast, goyter, matres
Pregnancies? Births? Miscarriages? Tatlo, yung isa nakunan ako katapos ng
Abortions? tita mo (pang apat).
Accidents? Injuries? Grade 4, nahulog ako sa kalabaw, nabali
yung braso ko (right) naging s shape siya,
sinemento ako dinala pa ako sa Maynila.
Prolonged pain or pain patterns? Wala naman, maayos pakiramdam ko.
Medications? Marami, ito sulatin mo sa puso ko,
Atorvastatin, Enalapril, Aspirin,
Levothyroxine (Goyter), Anaztrazole, etc.
Allergies? Wala, pero dahil cancer patient ako, hindi
pwede frozen foods (artificial) saken.
More on vegetable and fruits.
Family Health History
Recall as many genetic relatives as Si lolo Ben mo (spouse), may diabates
possible (parents, grandparents, siblings) sila sina kapatid niya. Ayon si lolo mo
with age, longevity, chronic illnesses (i.e., (father) nagkaroon liver cancer, kami rin
heart disease, stroke, diabetes, cancer, anak niya.
arthritis, Alzheimer’s).

Lifestyle and Health Practices Profile

Description of Typical Day Nagluluto, naglalaba, all around, wag
“Please tell me what an average or lang magbuhat ng mabigat. All around
typical day is for you. Start with ako, ako pa naglilinis.
awakening in the morning and continue
until bedtime.”
Nutrition and Weight Management ● Gulay na may sabaw, sigang,
• “What do you usually eat during a tinola, more on vegetables and
typical day? Please tell me the fruits, madalang lang ang meat.
kinds of foods you prefer, how
often you eat throughout the day, ● Madala lang.
and how much you eat?”
● May oras talaga, umaga, tanghali,
• “ Do you eat out at restaurants
hapon, gabi, kapag gutom mag
frequently?”
meryenda ka.
• “Do you eat only when hungry? Do
you eat because of boredom, ● Kami, namamalengke kami,
habit, anxiety, depression?” sumasama ako minsan, ako rin
• “Who buys and prepares the food nagluluto. NO VETSIN! Just salt.
you eat?”
• “Where do you eat your meals?” ● Dito (sa bahay).
• “How much and what type of fluids
do you drink?” ● Marami, 8 glass of water, minsan
sobra pa dahil sa pagtake ng
gamot.
Activity Level and Exercise ● Gigising, maglinis ng plato,
• “What is your daily pattern of maglinis sa labas, magluto.
activity?
• “Do you follow a regular exercise ● Palakad lakad ako, sa linis linis
plan? What type of exercise do lang, araw araw may lakad ako.
you do?”

• “Are there any reasons why you ● Wala naman, nakakapag exercise
cannot follow a moderately pa rin ako, kahit pa sayaw sayaw
strenuous exercise program?” lang sa umaga.
• “What do you do for leisure and
recreation?” ● Nanonood ako ng mga vlogger na
nakakatulong, pinapanood ko si
• “Do your leisure and recreational
Tekram pati si Kalingap Rab,
activities include exercise?”
Pugong Byahero. Pinapanood ko
yan kasi nagpapagawa sila bahay
 sa mga Aeta.
● Pagluluto ko, nageenjoy ako at
naeexercise rin ako.

Sleep and Rest  “Tell me about Wala mang pattern tulog ko, depende
your sleeping patterns.” kung pagod ako sa araw o hindi kapag
• “Do you have trouble falling asleep pagod maaga, kapag di pagod 12.
or staying asleep?”
● Wala naman.
• “How much sleep do you get each
night?”
● 5 hours na lang madalas.
• “Do you feel rested when you
awaken?” ● Basta nakapagpahinga nako,
• “Do you nap during the day? How presko nako.
often and for how long?”
• “What do you do to help you fall ● Basta nagpapahinga lang ako,
asleep?” yung nakahiga, madalang lang ako
makatulog ng hapon.

● Minsan, kapag nanonood ako

vlogs, napapaantok ako,
nakakatulog ako.

Substance Use ● Hindi ako nag-gaganyan, hindi

• “How much beer, wine, or other pwede.
alcohol do you drink on the ● Hindi rin ako pwede sa kape.
average?” ● Hindi rin ako nag ganyan, kahit
dati.
• “Do you drink coffee or other
● Hindi, lahat ng gamot ko may
beverages containing caffeine
(e.g., cola)? If so, how much and reseta galing sa doctor ko, di
pwedeng hindi, delikado.
how often?”
● Oo ito, Caltrate Plus, Centrum
• “Do you now or have you ever Plus, Vitamin B complex.
smoked cigarettes or used any
other form of nicotine? How long
have you been smoking/did you
smoke? How many packs per
week? Tell me about any efforts to
quit.”
• “Have you ever taken any
medication not prescribed by your
health care provider? If so, what
type, how much, and why?” 
“Have you ever used, or do you
 now use, recreational drugs?
Describe any usage.”
• “Do you take vitamins or herbal
supplements? If so, what?”

Self-Concept and Self-Care ● Sa ngayon, nagluluto luto na lang

Responsibilities ako sa bahay, tumatry ako mga
• “What do you see as your talents bago lutuin.
or special abilities?” ● Wala na sa akin iyon, matanda na.
• “How do you feel about yourself? Okay naman.
About your appearance?” ● Nanonood nood lang ako sa
Youtube at Facebook, madalas
• “Can you tell me what activities mga vlogs, para malibang.
you do to keep yourself safe, ● Wala na ako ganon, matanda na.
healthy, or to prevent disease?” ● Safe naman dito, may dalawa rin
• “Do you practice safe sex?” aso dito, at mga locks.
• “How do you keep your home ● Depende sa sinasabi ng doctor ko,
safe?” if need follow up pupunta ako.
• “Do you drive safely?” ● Bastat naramdam ko masakit
• “How often do you have medical ngipin ko papacheck up ako, sa
checkups or screenings?”  “How mata nagpaopera nako katarata.
often do you see the dentist or
have your eyes (vision)
examined?”
Social Activities Pagluluto, paglilinis, panonood ng vlogs.
“What do you do for fun and relaxation?”
• “With whom do you socialize most ● Sa kasama ko sa bahay, sina tita
frequently?” mo.
● Wala man.
• “Are you involved in any
● Okay lang, malinis at safe dito.
community activities?”
● Okay lang, may mga kasama
• “How do you feel about your naman ako sa bahay dito.
community?” ● Ngayon di na kagaya dati, wala na
• “Do you think that you have retired na.
enough time to socialize?”
• “What do you see as your
contribution to society?”
Relationship Kayo nina papa mo, tita, tito, lolo mo,
“Who is (are) the most important lahat kayo.
person(s) in your life? Describe your
relationship with that person.” ● Mahirap buhay noon, pero naging
• “Wht was it like growing up in your masaya naman.
● Okay naman kami nina lolo mo
family?”
umabot kami ng 50 years. Kina tita
• “What is your relationship like with mo naman, normal lang, maayos
your spouse?”  “What is your kami lahat.
relationship like with your ● Kasundo ko si Lola Zon mo,
children?” nagcacall kami palagi,
• “Describe any realtionships you nagkwekwentuhan.
have with significant others.” ● Wala na sila, namatay na, pero
• “Do you get along with your kasundo ko sila noon.
inlaws?”

• “Are close to your extended ● Oo naman, pero malayo sila sa

family?” akin.
• “Do you have any pets?”
● Yung pusa mo dito iniwan mo, yun
• “What is your role in your family?
Is it an important role?” inaalagaan ko ngayon.
• “Are you satisfied with your current ● (Di kona po tinanong to, sinabi
sexual relationships? Have there niya na po kasi kanina, wala na
been any recent changes?” ganun).
Values and Belief System Pamilya ko
“What is most important to you in life?”
• “What do you hope to accomplish ● Yung matapos si tita at tito mo.
in your life?” ● Katoliko ako, kaya imporante sa
akin nasa bible.
• “Do you have a religious affiliation? ● Kayo lahat ng pamilya ko, simula
Is this important to you?”  “Is a kay lolo mo hanggang sa inyo apo
relationship with God (or another ko.
higher power) an
important part of your life?”
• “What gives you strength and
hope?”
Education and Work ● Okay naman, gusto ko sana mag
• “Tell me about your experiences in college noon pero nakakahiya na
school or about your education.”  magpatulong kay Dara (Tita)
“Are you satisfied with the level of Solita.
education you have? Do you have ● Nanahi noon ako, last saan ako
future educational plans?” nagtahi sa may Holy Family
(School) pa, sumasama ka pa
• “What can you tell me about your noon.
work? What are your
● Oo, may mga nakakasundo ako
responsibilities at work?” noon.
• “Do you enjoy your work?” ● Okay naman, naging kaibigan ko
• “How do you feel about your lahat.
coworkers?” ● Kapag may reject sa gawa,
• “What kind of stress do you have kailangan pa ulitin lahat.
that is work related? Any major ● Si tito mo na nasa ibang bansa,
problems?” halos tumutulong dito ngayon.
• “Who is the main provider of ● Oo naman, kuntento ako sa
financial support in your family?” pinapadala ni tito mo.
• “Does your current income meet
your needs?”
Stress Levels and Coping Styles • Kapag siguro may problema sa
• “What types of things make you pamilya. Pero iniiwasan ko yan
angry?” dahil sa puso ko.
• Level 2, hindi pwede sa sobra
• “How would you describe the
stress.
stress level?”
• Nagpapahinga o nanonood ng
• “How do you manage anger or videos sa Facebook.
stress?”
• “What do you see as the greatest ● Kapag humihirap buhay natin.
stressors in your life?”
● Kinakausap ko si tito mo o Lola
• “Where do you usually turn for help
in a time of crisis?” Zon sa call.
Environment ● Dahil sa sakit ko, siguro iyong mga
• “What risks are you aware of in may kuryente, hindi pwede sa
your environment such as in your pace maker ko yon.
home, neighborhood, on the job, ● Ayun hindi ako pwede expose sa
or any other activities in which you may kuryente, sa Breast Cancer
participate?” ko di ako nakapagchemo dahil
may kuryente, kaya herbal na lang
• “What types of precautions do you
at gumaling ako.
take, if any, when playing contact
sports, using harsh chemicals or
paint, or operating machinery?” 
“Do you believe you are ever in
danger of becoming a victim of
violence? Explain.”