IV.

Health and Medical History

1. Present Illness
DISEASE SUFFERED MEDICAL ATTENDANCE REMARKS
1. Raul Zaragoza
2. Corazon
Zaragoza
3. Ramil Zaragoza
4. Catherin
Zaragoza
5. Rachel Ann
Zaragoza
6. Kimberly Brani
7. Catriona Elohr
Viado

2. Past Illness
DISEASE SUFFERED MEDICAL ATTENDANCE REMARKS
1. Raul Zaragoza
2. Corazon Thyphoid fever hospitalized
Zaragoza
3. Ramil Zaragoza
4. Catherin
Zaragoza
5. Rachel Ann
Zaragoza
6. Kimberly Brani
7. Catriona Elohr
Viado

3. Immunization Status of Children

DISEASE SUFFERED VACCINES GIVEN REMARKS
1. Kimberly Brani BCG, HEPA B, PENTA 1,
PENTA 2, PENTA 3, OPV
1, OPV 2, OPV 3, IPV, PCV
1, PCV 2, PCV 3, MR1,
MR2, OPV CATCH-UP
DOSE
2. Catriona Elohr BCG, HEPA B, PENTA 1,
Viado PENTA 2, PENTA 3, OPV
1, OPV 2, OPV 3, IPV, PCV
1, PCV 2, PCV 3, MR1,
OPV CATH-UP DOSE
4. Source of Medical Care (Regarding Pregnancy and Lactation)
 Health Center

5. Nutrition
Infant Feeding:
o __breastfed __ bottle
Type of Milk: Specify.________
o Condensed
o Evaporated
o Powdered
Age Supplemental Feeding Started:________________
Types of Foods Given:__________________

6. Food Beliefs Regarding Pregnancy and Lactation:

a. Foods not given during pregnancy:
b. Foods not given to mother during lactation:
c. Foods and drinks given to mother during pregnancy and lactation

7. Foods Preference and Habits of the Family:

Family: Date:
Address: Manila Health Department:
Assesses Justification
Family Coping Areas Point Scale
Problems Statement
Physical
1 2 3 4 5
Independence
Therapeutic
1 2 3 4 5
Competence
Knowledge of Health
1 2 3 4 5
Condition
Application of
Principles and 1 2 3 4 5
General Hygiene
Health Attitudes 1 2 3 4 5
Emotional
1 2 3 4 5
Competence
Family Living 1 2 3 4 5
Physical Environment 1 2 3 4 5
Use of Community
1 2 3 4 5
Resources
Comments:

Nurse’s Signature: