GENERAL HEALTH ASSESSMENT FORM
( HISTORY TAKING)
I- PERSONAL DATA
Name of Client/ Patient/ Repondent _____________________________________________
Home Address: _______________________________________________________________
Age: ______; Sex: _________; Civil Status: _____________ Religion:__________________
Occupation:______________________ ; Nationality:__________________________
In case of emergency, notify:______________________________________________
II- VITAL INFORMATION
A. Vital signs
T:______; P:________; RR:_______; BP:________
CR:_____; HT:_______; WT:_____________
B. Date Admitted: ____________________ Time:__________
C. Manner of Admission:______________________________
D. Chief Complaints: __________________________________________________________
___________________________________________________________________________
E. History of Present Illness: ____________________________________________________
III- APPEARANCE ON ADMISSION:
A. Physical
1. Body built: Slender:___________; Medium:______________; Obese______________
2. Appearance: Neat:____________; Untidy: _______________; Others: ____________
3. Skin Condition: Complexion: _________________________________
Color Texture: Smooth:______________ Rough:_________________
Presence of Lesions:_________________________________________
Others (specify): ____________________________________________
B. Level of Consciousness
Conscious: _____________________; Unconscious: ________________
Drowsy: _______________________; Comatose:__________________
Others (specify): ____________________________________________
C. Emotional Status:
Calm: _________________________; Disoriented:________________
Coherent:______________________; Incoherent:________________
Others (specify): ____________________________________________
IV. HISTORY TAKING:
A. Last Medical/ Surgical History:
__________________________________________________________________________
___________________________________________________________________________________________________________
_
B. Present Medical/ Surgical History:
_______________________________________________________________________
___________________________________________________________________________________________________________
_
C. Pertinent Family Medical/ Surgical History:
________________________________________________________________
___________________________________________________________________________________________________________
_
D. Social History:
1. Name of Spouse ( if married): _________________________________________
2. Number of Children: ________________________________________________
3. Highest Educational Attainment: ______________________________________
4. Source of Income: __________________________________________________
5. Vices/ Habits: ______________________________________________________
6. Hobbies/ Interests: _________________________________________________
7. House Owned: ____________; Rented:_____________; Shared: ____________
V- REACTIONS AND EXPECTATIONS:
A. Describe the Effects of Illness to Patient and Family:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
_.
B. Describe the Feelings About Examination and Treatment:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
_.
VI- NORMAL PATTERNS/ MODES OF FUNCTIONING:
A. Sleeping Patterns
Regular: _________________; Easily Awakened: __________________; Insomiac: ___________________
Sleeping Time: ________________________; Waking Up Time: __________________________________
B. Fluid Intake
Water: ________________; Beverages: ______________________; Others (specify): _________________
C. Elimination
Bowel Elimination: Daily: ____________________ Others ( specify ): ______________________________
Urine Frequency: ___________________________; Color: ______________: Odor: ___________________
D. Personal Hygiene
Bath: Warm_____________ ; Cold: _______________ ; Tepid: ________________________
Oral: Mouthwash: _____________________ ; Frequency: ___________________________
E. Motor Function
R/ Handed: _________________ ;Paraplegic: __________________ ; Quadriplegic;
______________________
L/ Handed: __________________ ; Hemiplegic: ____________________________
Facial Paralysis: ______________________________________________________
Degree of Contractures: Head: _________________ Neck ____________________
Arm: _________________; Fingers: _______________ ; Legs: __________________ ; Knee: _________________
F. Sensory Function
Extent/ Degree of Loss of Sensation: ____________________________________________________
G. Reflexes
Babinski: _______________________ ; Kernigs: ________________________ Others: _____________________
VII- IDIOSYNCRASIES
A. Allergies
Food: ________________ ; Drugs: ______________________ ; Others: ________________________
B. Preferences
Likes: Food: ______________________ ; Environment: _____________________________________
Others (specify) : _____________________________________________________________________
Dislikes: Food: ____________________________; Environment: ________________________________
Others (specify): ________________________________________________________________________
Interviewed by:____________________________________
Student
Date:________________________________________
___
