Biographical Data

Name Wonderwoman
Address Matanubong, Galimuyod Ilocos Sur
Phone 09094490642
Gender Female
Provider of History Patient
Birth date March 26, 1979
Place of birth Candon City General Hospital
Nationality or Ethnicity Filipino
Primary and secondary languages Iloco, Tagalog, English; Iloco
spoken, written and read; birth
languages
Marital status Married
Religious or spiritual practices Roman Catholic
Educational level College Graduate
Occupation and Working Status Caretaker/Landlady
Significant others or support Husband and son
persons
Reasons for Seeking Health Care
Reason for seeking health care Consistent severe headache five days prior to
(major health problem or consultation
concern)
Feelings about seeking health The client is comfortable in seeking health care; had
care (fears and past experiences) a good experience
History of Present Health Concern
Character Consistent severe headache
Onset Four days prior to consultation; condition is still the
same
Location Posterior part of the head transverse to the eyes
including left and right temples
Duration Headache occurs at noon onwards and worse at
night; consistent within the three days
Severity (1-10) Sleeping pattern of the client is affected
Pattern No past hospitalization; takes Advil (OTC) for
medication but doesn't completely relieve the pain;
headache is worse when the client uses phone, lies
down, and tired;
Associated Factors Unavoidable phone use; Stress from daily duty/work
Past Health History

Had no problems at birth; had experienced typhoid fever during the age of 14; wasn’t fully
immunized; has acute anemia for the past 25 years; had no previous history of surgery; had
given birth once during the age of 27; had not been involved in any accidents or injuries;
had no experience of an prolonged pain or pin patterns; had a regular intake of ferrous
sulfate; has allergies to crabs and shrimps
Family Health History

Her family from the second generation up until now is suffering from anemia; No death
caused by anemia was stated
Review of Systems for the Current Health Problem
Skin, hair, nails: Has a skin color of brown; has a body temperature of 36.4˚C;
has a dry, thin hair; has no excessive sweating; has no rashes;
has no lesions; suffering from mild balding; no dandruff; nails
are pale and slightly dirty
Head and neck: Has no swelling; sometimes experiencing stiffness of neck; has
no difficulty in swallowing; has no sore throat; has no enlarged
lymph nodes
Ears: Has no problem in hearing; has not experienced any buzzing or
ringing in ears; has not experience earaches; has no drainage
from ears
Eyes: Has astigmatism; has no eye infection; has no redness of the
eyes; has no excessive tearing; consecutive blinking of eyes;
has no presence of halos around lights; near sighted; has not
experienced loss of side vision; has no presence of black spots
in visual fields; has no double vision; has experienced eye pain
when exposed to brightness
Mouth, throat, nose and Uses complete set of denture; has no mouth lesions; has n
sinuses: hoarseness of voice; has no rhinorrhea; has no nasal
obstructions; has not experienced frequent colds;
Thorax and lungs: Has no difficulty in breathing; has not experienced chest pains;
has no shortness of breath during routine activity; has no
orthopnea; has no presence of cough; has no hemoptysis; has
no respiratory infections
Breast and regional Has no lumps or discharge from nipples; has no swollen and
lymphatics: tender lymph nodes in axilla; has no dimpling or changes in
breast size
Heart and neck vessels: Has 100/70 blood pressure; has no ECG tracing or findings;
has not experienced chest pain; has no edema
Peripheral vascular Has no swelling or edema; not suffering from feet pain; has not
experienced cramping; has no sores on legs; has slight bruises
due to excessive working; has rough texture of legs and feet
Abdomen Sometimes suffer from indigestion; has no difficulty in
swallowing; not experiencing nausea on normal basis; no
vomiting; no abdominal pain; no gas present; has not
experience jaundice; has no hernia
Female Genetalia: Has no sexual problems; has no sexually transmitted disease;
has no problems in voiding; has first experienced menstruation
at the age of 17; has irregular cycle of menstruation; has a
pregnancy once; has no problem with delivery; has not
experienced abortions; has no pelvic pain; no use of birth
control; has not reached menopausal stage; has no use of
hormone replacement therapy
Anus, rectum, and Has regular bowel habits or movement; has no pain with
prostate: defecation; not suffering from hemorrhoids; has no blood in
stool; sometimes experience constipation; sometimes
experience diarrhea
Musculoskeletal: Has no swelling; has no redness; has slight bruises on legs due
to excessive working; has no stiffness of joints; can perform
activities in daily living; has normal muscle strength
Neurologic: Has no changes in general mood; has a normal behavior; has
experienced depression last month; no anger issues; no
concussions; has episodes of headache for four consecutive
days; no loss of strength or sensation in normal basis; has
normal coordination; has no difficulty in speaking; sometimes
suffering from memory problems; inability to recall people and
names; has experienced over thinking; has no difficulty in
learning
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

COLLEGE OF NURSING

In Partial Fulfillment in the Course

Health Assessment (Skills Laboratory)

“COMPLETE HEALTH HISTORY”

Submitted by:
La Madrid, Hanna Mae B.
BSN – 1F
Group 2

Submitted to:
Mrs. Rizza Abinsay
Instructor

February 20, 2019