Patient Data Sheet

I. Demographic Profile a. Gender y Female ///// y Male - ///// b. Age y y y y y y 18 - /// 53 - / 17 - // 19 - // 25 - / 37 - /

c. Year of Birth y 1993 - // y 1992 //// y 1991 / y 1974 / y 1957 / y 1986 / d. Occupation y Student /////-// y Employee /// e. Home Address y Paranaque //// y Cavite - // y Pasig - / y Makati / y Quezon - / f. Work Address y Pasay - /////-///// g. Religion y Roman Catholic /////-//// y Born Again Christian - / h. Marital Status y Single - /////-//// y Married - /

II.

Present Condition a. State the current health and wellness condition of your case (Ranges of current health status; 10 as the highest, 1 as the lowest) y 8-10 - /////-//// y 5-7 / y 1-4 b. Highlight pertinent and significant health and wellness related events y None- /////-/// y Diarrhea - / y Colds - / c. Include interventions and/or activities done by your case to maintain a health/wellness condition or any activity which Is currently being done to solve or alleviate a certain health/wellness Issue y Exercise- ///// y Healthy food intake - ///// y Medication-/// d. Include medications currently taken and determine the reason for its consumption y Medication(loperamide)- /

III.

Past Condition a. Include previous medical conditions experienced by your case y Typhoid - / y Dengue - // y Measles- / y Allergies - / y Impacted Wisdom - / y Ovula problem - / b. Highlight medical intervention done like surgery, drug therapy etc. y Surgery- // y Blood transfusion - / y Medication - // c. Indicate the outcomes to the above mentioned y Cured ///// y None - /////

IV.

Family History a. Trace the pertinent health related historical conditions from the grandparents

Maternal Hypertension // Diabetes ///

Heart problemCancerRespiratory condition (asthma)- // y Paternal Hypertension // Diabetes // Heart problemCancer- / Respiratory condition (asthma)- / None - ///

V.

Social History a. Include the assessment of lifestyle, social activities and other related facts y Active - /////-// y Sedentary - ///

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Benido Catacio Jessa Pacho Jane Charmaine G. Po Christine Kay Del Mundo Kier Arenas Lianne Alessandra Garcia Joji G. Baba Mariel Rennes C. Narcilla Rizeile Go Florencio P. Bacillo JR.