COMPREHENSIVE NURSING HEALTH HISTORY

Date: ___________________________

I. BIOGRAPHICAL DATA:
a. Name: ____________________________________
b. Address: ___________________________________________________________________________________
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c. Age: ___________
d. Sex: ___________
e. Civil Status: _____________________
f. Date of Birth: _____________________
g. Religion: ________________________
h. Occupation: _____________________
i. Mother: ________________________
j. Father: _________________________
k. Ordinal Position: __________________________
l. Type of Service: _____________________________
m. Source of Information: ___________________
n. Attending Physician: _____________________________

II. REASON FOR SEEKING CARE (CHIEF COMPLAINT): _______________________________________________

III. HISTORY OF PRESENT ILLNESS:

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IV. PAST HEALTH HISTORY:

a. Childhood and Infectious Diseases: ______________________________________________________________
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b. Immunizations: _____________________________________________________________________________
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c. Allergies: ___________________________________________________________________________________
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d. Medications Taken: __________________________________________________________________________
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e. Major Surgeries and Previous Hospitalizations: ____________________________________________________
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f. Injuries: ___________________________________________________________________________________
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V. FAMILY HISTORY:
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VI. PSYCHOSOCIAL HISTORY AND LIFESTYLE:

a. Alcohol Use: ________________________________________________________________________________
b. Drug Use: __________________________________________________________________________________
c. Tobacco Use: _______________________________________________________________________________
d. Domestic and Intimate Partner Violence: _________________________________________________________
e. Sexual Practice: _____________________________________________________________________________
f. Travel History: ______________________________________________________________________________
g. Work Environment: __________________________________________________________________________
h. Home Environment: __________________________________________________________________________
i. Hobbies and Leisure Activities: _________________________________________________________________
j. Stress: _____________________________________________________________________________________
k. Education: _________________________________________________________________________________
l. Economic Status: ____________________________________________________________________________
m. Ethnic Background: __________________________________________________________________________
 GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

1. Health Perception – Health Management Pattern

Before Hospitalization: _____________________________________________________________________
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During Hospitalization: _____________________________________________________________________
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2. Nutritional – Metabolic Management Pattern

Before Hospitalization: _____________________________________________________________________
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During Hospitalization: _____________________________________________________________________
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3. Elimination Pattern
Before Hospitalization: _____________________________________________________________________
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During Hospitalization: _____________________________________________________________________
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4. Activity - Exercise Pattern

Before Hospitalization: _____________________________________________________________________
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During Hospitalization: _____________________________________________________________________
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5. Sleep – Rest Pattern

Before Hospitalization: _____________________________________________________________________
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During Hospitalization: _____________________________________________________________________
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6. Cognitive – Perceptual Pattern

Before Hospitalization: _____________________________________________________________________
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During Hospitalization: _____________________________________________________________________
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7. Self-Perception – Self-Concept Pattern
Before Hospitalization: _____________________________________________________________________
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During Hospitalization: _____________________________________________________________________
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8. Roles – Relationships Pattern

Before Hospitalization: _____________________________________________________________________
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During Hospitalization: _____________________________________________________________________
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9. Sexuality – Reproductive Pattern

Before Hospitalization: _____________________________________________________________________
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During Hospitalization: _____________________________________________________________________
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10. Coping – Stress Tolerance Pattern

Before Hospitalization: _____________________________________________________________________
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During Hospitalization: _____________________________________________________________________
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11. Values – Beliefs Pattern

Before Hospitalization: _____________________________________________________________________
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During Hospitalization: _____________________________________________________________________
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PHYSICAL EXAMINATION
 REVIEW OF SYSTEMS

1. Constitutional:____________________________________________________________________________
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2. Head, Eyes, Ears, Nose, Throat (HEENT):
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3. Respiratory:______________________________________________________________________________
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4. Cardiac:_________________________________________________________________________________
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5. Vascular:________________________________________________________________________________
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6. Gastrointestinal:__________________________________________________________________________
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7. GenitoUrinary:____________________________________________________________________________
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8. Neuromuscular:___________________________________________________________________________
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9. Emotional:_______________________________________________________________________________
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10. Hematological:___________________________________________________________________________
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11. Rheumatic:_______________________________________________________________________________
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12. Endocrine:_______________________________________________________________________________
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13. Dermatological:___________________________________________________________________________
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 LABORATORY SHEET

Laboratory Test: Hematology and Blood Chemistry Date: July 19, 2019

Component Normal Values Results Implication

White Blood Cell 4.50 – 11.0 11.4 x10^9/L Possible infection

Red Blood Cell 4.2-5.4 4.42 x10^12/L Within normal range
Hemoglobin 120-160 129 g/L
Hematocrit 0.38-0.47 0.40
MCV

Radiographic Test (i.e. x-rays, ultrasounds, angiography, etc.):

Results/Impression:
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 DRUG STUDY
Name General Action Specific Action Indication Side/Adverse Effects Nursing Consideration
Generic Name:

Brand/Trade Name:

Route:

Dosage:

Frequency:
 NURSING CARE PLAN

Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Interventions
Subjective Cues:

Objective Cues: