University of the Philippines Manila

The Health Sciences Center

COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St. Ermita, Manila

Melissa Jean G. Hipolito 2008-58106

NURSING HEALTH HISTORY
Date of Interview: (input)

A. BIOGRAPHIC DATA
Name:
Address:
Birth Date/Place:
Age:
Sex:
Race:
Religious Orientation:
Health care financing and usual source of medical care:
Mother's name: _____________________________________________________ Age: ___________________
Educational Attainment: _______________________________________ Occupation: ____________________
Father's name: ______________________________________________________ Age: ___________________
Educational Attainment:________________________________________ Occupation: ____________________
Number, sex and age of children: (Example: 3-F4 F3 M2) ___________________________________________

B. PRESENT ILLNESS AND HISTORY OF PRESENT CONDITION

Eye discharge Jaundice
Ear discharge Colic
Vomiting Diarrhea
Mouth sores Constipation
Nasal discharge Parasitism
Cough Fever
Colds Skin lesions
Cyanosis Wet navel
Others (specify)
(Note onset, severity, duration, method of
relief of symptoms:
)

(INPUT)

C. PAST HISTORY
A. Maternal and Prenatal History
Gravida Para Pre-natal check-up (for this pregnancy baby) Yes No
Where:
No. of Prenatal Visit:
Illness during this pregnancy (specify):
X-ray exposure: At what month/trimester of pregnancy:
Drug Intake: Yes No Nature of drug
Reason for taking the drug:
When (trimester) Nature of drug
History: □ Stillbirth □ Spontaneous Abortion □ Neonatal Death □ Tobacco Use □ Alcohol use

B. Birth History:
Full Term Premature Weight Length
Place of Birth: Hospital Home Others
Assisted by: Physician Nurse Nurse Midwife Others
Manner of delivery: Cesarean Forceps Vaginal
Indication
Presentation: Cephalic Breech Others
C. Maternal Complications (During Pregnancy of this child)
Hypertension Fever infection
Bleeding Others (specify)
Polyhydramnios ____________________ Oligohydramnios __________________

D. Neonatal Complications
None Incubator care
Cyanosis Jaundice
Prematurity Difficult respiration
Others (ex. Congenital anomalies)

E. Past Illness (check if applicable)

Cough Measles
Colds Parasitism
Diarrhea Skin disease
Fever
Hospitalization: No Yes
If yes, where
For what
When
Duration

F. Family History (indicate if mother or father)

□ Asthma □ TB □ Allergy □ Heart Disease □ Cystic Fibrosis □ Hypertension
□ Diabetes Mellitus □ Cancer □ Systemic Lupus Erythematous

D. FUNCTIONAL HEALTH PATTERN

1. Health Perception and Health Management Pattern
(input)

2. Nutritional and Metabolic Pattern

(input)

3. Elimination Pattern
(input)

4. Motor Development
(input)

5. Cognitive-Perceptual Pattern
(input)

6. Activity-Exercise Pattern
(input)

7. Sleep-Rest Pattern
(input)

8. Role-Relationship Pattern
(input)

9. Independence-Dependence Pattern
(input)

10. Discipline/Temperament
(input)

SUMMARY FINDINGS: (input)

MMDST RESULT: Date Performed:

 Physical Examination for Babies

General Information
Name of Client:________________________________________ Age: ___ Sex: ___ □ PGH Ward:___ Bed#.:___
Home Address: ____________________________________ Chief complaint: ___________________________
Examiner:_______________________________

Vital Signs/Anthropometric Measurements External canal: □ Impacted cerumen

T__°C □ oral □ axillary □ rectal □ Discharge: □ Foul smelling □ Serous
PR _____ beats/ min □ regular □ irregular □ Purulent □ Mucoid
HR _____ beats/ min □ regular □ irregular Gross hearing: (test w/bell or call name:blink,head or eyes
RR _____ breathes/ min □ regular □ irregular toward sound) □ Symmetrical □ Deafness R L
BP __________ □ sitting □ standing Others: □ Skin tags or pits @ __________________
Height ___cm <9mos: HC:__cm CC: __cm AC:__cm Eyes
Weight ___kg Lids: □ Symmetrical □ Edema/Swelling R L □ Ptosis RL
Periorbital region: □ edema □ sunken □ discoloration
General Survey Conjunctiva: □ pinkish □ pale □ lesion □ discharge
LOC: □ Conscious □ Drowsy □ Stuporous □ Comatose Sclera: □ Anicteric □ Subicteric □ Icteric □
□ Others: ______________________ Hemorrhages
General appearance: □ Signs of distress □ Pain Cornea & Lens: □ smooth □ clear □ lesions □ opacity
□ Cardiorespiratory □ Anxiety □ Arcus senilis
Development: □ endomorph □ mesomorph □ ectomorph Pupil size: □ equal □ unequal
□ well □ fairly □ poorly R= ___mm L= ___mm
□ looks according to age □ looks younger/older Reaction to light: R □ brisk □ sluggish □ fixed
Tone: □ well-flexed □ slightly flexed □ extended L □ brisk □ sluggish □ fixed
Nutrition: □ well nourished □ obese □ cachexic Reaction to accommodation: □ uniform □ unequal
Emotional state: □ calm □ worried □ restless □ tense Extra ocular muscle tests (6 mos): □ Symmetrical
□ Others: ________________________ □ Asymmetrical
Expiratory Grunt: □ None □ on auscultation □ naked eye Convergence: □ uniform □ unequal
Focus w/ both eyes (6 mos): □ Symmetrical
Skin □ Asymmetrical
General color: □ Pallor □ Jaundice □ Flushed □ Cyanotic Visual acuity (6 yrs): □ Grossly normal □ Wears
□ Acrocyanotic eyeglasses/ contact lenses
Texture: □ Smooth □ Rough □ Cracking Others: □ Red reflex □ Strabismus
□ others: ____________
Turgor: □ Good □ Fair □ Poor Nose
Temperature: □ Warm □ Cool □ others: _____________ Nasolabial Fold: □ Symmetrical □ Shallow R L
Moisture: □ Dry □ Wet/clammy □ oily Nasal Flaring: □ None □ Just visible □ Marked
Lanugo: □ Abundant □ Thinning □ Few Septum: □ Midline □ Deviated □ Perforated
Others: □ Petecchiae □ Ecchymosis □ Milia Mucosa: □ Pinkish □ Pale □ Reddish
□ Vernix caseosa □ Stork bite □ Discharge: □ Serous □ Purulent □ Mucoid
□ Mongolian spots □ Lesions/ rashes: __________ □ Bloody
□ Birth marks: @ ______________ Patency: □ both patent □ obstructed R L
□ Edema : □ Pitting □ Non-pitting (Grading: ___) □ Masses/ Lesions: ________________________
□ Pedal L R Gross smell: □ Symmetrical □ Olfactory deficiency R L
Sinuses: □ Tender □ Non-tender
Head
Head to body ratio:__:__ Mouth
Configuration: □ Normocephalic □ Others:___________ Lips: □ Pallor □ Cyanosis □ Drynes □ Lesions □ Clefts
□ Masses/Swelling ___________________ Tongue: □ Midline □ Deviated R L □ Atrophy
Anterior Fontanel: □ Closed □ Open: ________________ □ Fasciculation □ Lesions
□ Sunken □ Bulging Gums: □ Pinkish □ Pale □ Bleeding □ Tenderness
Posterior Fontanel: □ Closed □ Open: ________________ Mucosa: □ Pinkish □ Pale □ Cyanotic
□ Sunken □ Bulging Speech: □ Intact □ Sturred □ Aphasic □ Others: _____
Hair: □ Fine □ Coarse □ Dry Others: □ Epstein pearls □ Natal teeth
□ Normal distribution □ Alopecia Sucking Reflex: (+) (-) Swallowing Reflex: (+) (-)
Scalp: □ Clean □ Dandruff □ Lice □ Lesions Extrusion Reflex: (+) (-)
□ Others: ____________________
Pharynx
Ears Uvula: □ Midline □ Deviated R L
External Pinnae: □ Normoset □ Symmetrical □ Flat Mucosa: □ Pinkish □ Pale □ Reddish
□ Folded □ Firm □ Soft □ Instant recoil Tonsils: □ Not inflamed □ Inflamed
□ Tenderness □ Gross abnormalities: ____________
Neck (examine while lying flat on back) Palpation: □ Muscle guarding □ direct tenderness □
Trachea: □ Midline □ Deviated R L Rebound tenderness
Lymph nodes: □ Nonpalpable □ Palpable/enlarged
□ Tender Genito-urinary System
Thyroids: □ Nonpalpable □ Enlarged
Others: □ Normal ROM □ Neck rigidity □ Redundant skin Female
□ Posterior fat pad Labia: □ Symmetrical □ Asymmetrical
□ NVE at __° angle R L Masses □ Lesions at _______________
□ Pinkish □ Discoloration □ Edema
Chest and Lungs Clitoris: □ Prominent □ Covered
Inspiration- Expiration ratio: ___:___ Vaginal orifice: □ Discharge: □ Purulent □ Bloody foul
Shape of chest: APL ratio: ___(AP) :___ (L) smelling □ White
□ Barrel □ Funnel □ Pigeon □ Others: ___________ Others: □ Swelling □ Lumps or nodules at ___________
Upper Chest expansion: □ Synchronized □ Lag on
Expiration □ Severe See-saw Male
Lower Chest expansion: □ No retraction □ Just visible □ Penis: □ Discharge:____________________________
Marked □ Nodular growth lesions at ________
Xiphoid Retractions : □ No retraction □ Just visible □ □ Tenderness
Marked □ Length: ______________
Tactile Fremitus: □ Symmetrical □ Dec/ Inc at _____ R L Scrotum: □ Equal □ Tenderness □ Enlargement R L
Percussion: □ Resonant □ Dullness at __________ R L □ Undescended R L □ Nodules/growths/lesions at ______
□ Hyperresonant at __________ R L □ Swelling
Breath sounds: □ Vesicular □ Bronchovesicular at ______ Others: □ Hernia □ Hydrocele □ Hypospadius
□ Bronchial at ____________ □ Epispadius □ Chordee
Abnormal breath sounds: □ Wheezes _____ R L
□ Rales___ R L □ Friction rub ___ R L □ Rhonchi ___ R L
Back and Extremities
Heart Peripheral pulses: □ symmetrical □ regular □ warm
Pericordial area: □ Flat □ Bulging □ Normodynamic □ absent □ faint
□ Hyperdynamic □ Tenderness □ Heave □ Thrill □ Weak □ Strong □ Bounding
PMI at ___________ Apical beat: ________ beats/min Nail: □ pink □ pale □ cyanosis □ inflammation □ clubbing
Heart sounds: □ Distinct □ Faint □ delayed cap refill
S1 __S2 @ base S1 __S2 @ apex
Extra sounds □ S3 □ S4 Joints: □ redness □ warmth □ crepitation
□ Murmur, grade __ best heard at_______ □ Swelling at _______________________
□ Tenderness at _______________________
Breast and axillae □ Full ROM □ Decreased ROM at ____________\
Size and symmetry: □ Equal □ Unequal Muscle: □ size equal □ atrophy at ______________
Contour: □ Masses _______ R L □ Dimpling _____ R L □ Normal tone □ Hypertonic □ Flaccid
Skin: □ Redness □ Edema Discharge: (+) (-) □ Fasciculation □ Tics
Color:______ □ Tremors □ Strength equal
Tenderness: □ Tender □ Non-tender □ Weakness at ____________________
Bud: □ None □ Scant □ Palpable: _____ mm □ Paralysis at _____________________
Nipple and Areola: □ Inversion □ Flattening or retraction Spine: □ midline □ Dimple
□ supernumerary □ galactorrhea □ Scoliosis at __-__ □ Kyphosis at __-__
□ Lordosis at __-__
Abdomen Kidney: □ CVA Tenderness
Skin: □ Dilated veins □ Striae □ Scars □ Rashes Others: □ Simian crease □ Extra digits □ Fused digits
□ Lesions at ______________________ □ Abnormally shaped fingers □ Dislocated hip
□ Visible peristalsis Plantar surface of foot (creases): □ scant anterior
Umbilicus: □ Sunken □ Bulging □ Hernia □ 1/3 anterior □ sole has few □ over entire sole
Configuration: □ Flat □ Globular □ Protuberant
□ Scaphoid Palmar and plantar reflex: (+) (-)
□ Symmetrical □ Asymmetrical Tonic neck reflex: (+) (-)
□ Masses at: _______________________ Moro reflex: (+) (-)
Bowel sounds: □ Normoactive □ Hyperactive Walking Reflex: (+) (-)
□ Hypoactive □ Absent Rate: _______/min Babinski Reflex: (+) (-)
Bruit: □ Absent □ Present at ________
Liver (1-2 cm below RCM): □ Palpable □ Nonpalpable
Pecussion: □ Tympannic □ Hypertympannic
□ Fluid wave □ Shifting dullness