College of Health Sciences Education

3rd Floor, DPT Building

Matina Campus, Davao
City
Telefax: (082) Phone No.: (082)300-5456/300-0647 Local 117

NCM 101n/L – Health Assessment

Activity No. 1 - Health History Taking

I. Identifying Information (Biographical Data)

Name: Occupation:
Age: Date of Health History Taking:
Gender: Chief Complaint:
Date of Birth: Source of Information:
Place of Birth:

II. History of Present Illness: (Explain in paragraph format)

III. History of Past Illness: (Explain in paragraph format)

1. Medical Health History

2. Surgical History (If any)

3. Medication taken (Prescription, Over-the counter)

4. Allergies
5. Communicable diseases experienced at present or in the past. (If any)

6. Injuries and accidents experienced in the past (if any)

7. Special Needs

8. Blood Transfusions
9. Childhood Illnesses experienced

10. Immunization records (Specific vaccines)

IV. Family Health History (Trace and Draw the Genogram, you may provide a Legend on
symbols)
V. Social History (May answer the following if currently present)
1. Alcohol intake; Cigarettes intake; Drugs intake

2. Experienced Domestic Violence or Intimate partner violence

3. Sexual Practice or preferences

4. Travel history (Local, Abroad)

5. Working environment (Identify the potential hazards)

6. Home environment (Identify the potential hazards)

7. Physical activities (Hobbies, leisure activities)

8. Stress experiences (Identify the factors that may contribute to stress)

9. Coping mechanism (Identify a coping management that helps cope with the stress
experienced)

10. Economic status (Discuss the economic status of your family)

11. Religion (Discuss the patient’s religious affiliation and beliefs)

12. Ethnic Background (Describe the ethnic and cultural background of the patient)
 13. Roles and relationships

14. Characteristic Patterns of Daily Living and Functional Health Assessment

15. Health Maintenance activities

VI. Identify least Five (5) Nursing Priority Problem based on your gathered data from
your client.

1.

2.

3.

4.
 5.

VII. Using the NCP format. Create Two (2) Nursing Care Plan based on the identified
priority problem.

a. One (1) Actual Problem

b. One (1) Potential / High Risk Problem

Submitted by:

Name of the student:

Subject:
Code: