QUESTIONS: FINDINGS:
I. Biographical Data
Name
Age
Gender
Date of Birth
Place of Birth
Address
Contact Number
Occupation
Civil Status
Religion
Nationality
Ordinal Position in the Family
Date of Interview
Chief Complaint/s
Diagnosis
Informant: (If applicable)
Vital Signs:
Temperature
Pulse Rate (Apical)
Respiration Rate
Blood Pressure
O2 Saturation
II. Reason for seeking health care
a. Reason
Is there something related to
your health that worries you?
What is your major health
concern?
b. Feelings
Are you comfortable with seeking
care from this organization? Past
experiences, good or bad?
III. History of Present Illness
Can you describe the quality of
pain you are feeling? (Sharp,
shooting, dull, throbbing, aching,
burning, cramping, or crushing)
When did it start?
What did you do to alleviate
pain? Do have any idea if there’s
something that can trigger it?
Is there anything that makes it
better or worse?
Does the pain radiate in part of
your body?
From 1 to 10, can you rate the
pain? From 10 being the highest
and 1 being the lowest.
IV. Past Health History:
a. Childhood Illnesses
Do you have any problems at
birth?
Are there any complications?
Do you have any childhood
illnesses?
b. Immunizations
What immunization vaccine you
acquired?
c. Allergies
Do you have any allergies?
What food or medications that
triggers your allergy?
d. Accidents/Injuries
Have you encounter any
accidents that leads to injuries?
Or severe injuries?
e. Hospitalization
Have you been hospitalized?
What are the causes? Is it related
to previous disease? Or for
surgery?
Are you taking any medications?
V. Family Health History
Are there any health conditions
that runs in your family?
What is the lifestyle related
habits of your family particularly
your mother and father?
What are the observed health
conditions you can observed to
your maternal and paternal side?
What is the common life
expectancy in your family?
VI. Genogram
VII. Lifestyle and Health Practices
a. Activities of Daily Living
b. Description of a typical day
Please tell me what an average or
typical day is for you. Start with
awakening in the morning and
continue until bedtime
c. Nutrition and Weight Management
In 24 hours, how many liters of
water do you usually take?
What type of food you usually
eat daily?
What are your eating habits?
How many times do you eat
every day?
Are there any changes regarding
in your eating pattern?
d. Elimination Pattern
How frequent do you void daily?
How many ml of urine you
urinate every urination?
Are there any abnormalities
observed in the characteristics of
your urine? (Color, odor, etc.)
How frequent do you defecate
every day?
Can you describe the
characteristics of your stool?
e. Activity level and exercise
Do you exercise regularly?
What kind of exercise do you do?
What exercise plan do you have?
f. Sleeping Pattern
What is your sleeping pattern?
Are you getting enough sleep
every day? How many hours
exactly?
Do you have any sleeping
problems?
Do you feel rested when sleeping
at night?
g. Use of medication or other
substance
Do you take vitamins or herbal
supplement? If so, what?
Do you drink coffee or other
beverages containing caffeine
(e.g. cola)? If so, how much and
how often?
h. Self-concept and self-
responsibilities
What do you see yourself as your
talents or special abilities?
How often do you have medical
checkups or screening?
How often do you see the dentist
or have your eye checkup?
i. Relationships
Who is the most significant
person in your life?
Is there someone who can help
you handle the situation better?
What is your role in your family?
j. Education and Work
Tell me about your experiences in
school or about your education
Do you enjoy school?
How do you feel about your
current classmates?
k. Stress Level and Coping Styles
What type of things that makes
you angry?
How do you manage anger?
What do you see as your greatest
stressor in life?
VIII. Competencies
a. PHYSICAL
Can you perform you ADL
activities daily like the usual?
Are you feeling loss of strength or
coordination lately? How
frequent and when did it started?
What type and state the level of
activity you usually do on a
regular basis? Does it improve
your muscle strength?
b. EMOTIONAL
Who is the most significant
person in your life?
Is there someone who can help
you handle the situation better?
What is your role in your family?
What are the greatest stressors
in life that effects or influence
you?
From 1 to 10, can you rate the
stress level? From 10 being the
highest and 1 being the lowest.
c. MENTAL
Do you have any strange
thoughts that affects your daily
living?
Are you experiencing any
memory problems?
Are there any episodes of
anxiousness lately? What are the
triggering factors?
Do you have any philosophical
belief in life? Can you state it?
d. SPIRITUAL
Are you affiliated in any religious
group?
How is your relationship with
God?
How does your spirituality and
faith influence your everyday
living?
e. SOCIAL
Do you still have time to do
leisure activities?
What leisure activities do you do?
With whom do socialize often?
What community activities or
organization you are currently
involve with?
f. ENVIRONMENT
Where are you currently living?
Do you own a house?
Can you describe the type of
neighborhood you have?
Can you observe any
environmental hazard around
you?
Does your neighborhood have
enough access to community
facilities particularly to health
care?
