I.

Demographic Data

Name: John Andrei Mojica

Address: 331 Moldex compound brgy. Sampaloc I, Dasmariñas, Cavite

Age: 1 year 9 months

Gender: Male

Date of Birth: March 24, 2008

Nationality: Filipino

Mother’s Name: Anabelle Mojica

Father’s Name: Adrian Mojica

Grandmother’s name: Aida Reyes

Religion: Catholic

Information provided by the grandmother who is coherent and reliable

II. Reason for seeking health care:

Whenever the parents seek medical care for the child, it is usually due to monthly
check-up.

III.History of Present Illness

The client has no illness in present time.

IV. Past Medical History

There is no history of problem at birth based on the client’s grandmother.

A. Pediatric or Childhood Illness

The grandmother verbalizes that her grandson is healthy

1
 B. Immunization

The client is fully immunized child. He already completed the

recommended vaccines for him.

C. Injuries/Accidents

According to the grandmother of the child, her grandson has no history of

injuries and accidents.

D. Allergies

There are no known allergies based on the grandmother’s claim.

E. Medications

Currently the client is not taking any medications, supplements and the
like.

F. Hospitalization
According to grandmother, the child has not been hospitalized and had
never gone any operation due to illnesses, diseases or accidents.

V. Family Medical History

(A genogram is shown on the next page)

Interpretation of genogram

On the maternal side, JAM’s grandmother A.R. whose 50 years old is alive and

well his grandfather R.R. is also 50 years old is alive and well. JAM’s uncle A.R. is 25

yeard old alive and well. His mother A.M. 24 years old alive and well, she delivered her

2
newborn son 3 weeks ago. On the paternal side JAM’s grandmother L.M. 51 years old is

alive and well. His grandfather is 53 years old alive and well. JAM has 2 aunt and 1

uncle, all of them are alive and well. JAM’s father had an accident and damaged his

spinal cord. He is currently bedridden. JAM’s sibling a 3 week old infant is currently in

good state.