NURSING HEALTH HISTORY BIOGRAPHIC DATA

1. Name: Rey Pecardal 2. Present address: Block 30 Lot 15 Macopa street Mangga 3, Nagpayong, Pinagbuhatan, Pasig City 3. Age: 16 y/o 4. Gender: Male 5. Race/Ethnic Affiliation: Filipino 6. Marital status: Single 7. Occupation: Student 8. Religious Orientation: Roman Catholic 9. Health care financing and usual source of medical care: His father. CHIEF COMPLAINT: y None at the time of history taking. C. History of present illness y None at the time of history taking. D. Past History y During childhood the client had chicken pox, occasional cough, fever and colds. y He has complete immunization taken. y Have allergies to shrimps. y No history of accident. y The client has not been hospitalized before because of a disease. E. Family History of Illnesses y Both parents have hypertension. y His grandfather has hypertension. y He and his father have allergies to shrimps. F. Functional Health Pattern Health perception and health management pattern y Perceives own health with no problem. y Seldom to catch colds. Three to four times a year. y He believes that eating vegetables will result to good health of the family. y Does not smoke and drink alcoholic beverages. y Strictly follows the advices of a doctor and nurse. y Feels that she has a comfortable environment when health personnel practice well. y Does not have traditional concepts of health.

Nutritional and metabolic pattern y Has good appetite. y No eating difficulties. y Heals well. y No skin problems. y No dental carries. y No supplements. y Typical diet consists of: Breakfast 2 pandesals, 1mug of coffee Lunch 1 cups of rice, 4 tbsp. pinakbet Dinner 1 cups of rice, 4 tbsp. pinakbet Water 8 or more glasses a day y The family used to eat fried and salty foods. Elimination pattern y Defecates once a day. Stool is soft, brown to dark in color. No pain and difficulty in defecating. y Frequency of urination depends on the water intake. Urine was described as light yellow in color. No pain in urinating. y No excessive sweating. Activity Exercise Pattern y Able to perform daily activities well. y Has no regular exercise. y He is currently studying. y Perceived ability (code level) for: y Feeding : level 0 y Bathing : level 0 y Toileting : level 0 y Bed mobility : level 0 y Dressing : level 0 Sleep-rest pattern y Usually sleeps at about 8 hours and above. y No difficulty in sleeping and no sleep medications. y Sleep is continuous. y Have afternoon naps if there is no work on the day. Cognitive-perceptual Pattern y No eyeglasses and no visual acuity problems. y No hearing problems. y No discomfort or pain. Self-perception and Self-control Pattern

y y y y y

Grooming : level 0 General mobility : level 0 Cooking : level 0 Home maintenance : level 0 Shopping : level 0

y y y

Describes himself as a normal person. He worries when his parents argue. Financial problems make him worry.

Role-relationship Pattern y Sees no problems difficult to manage. y Has close friends in neighborhood and does not feel isolated or lonely. y He is a student being financed by his parents. y His needs are being provided by his parents. y They have family discussions. Sexuality-reproductive pattern y He is in adolescent stage. y At puberty age. Coping with stress tolerance problem y Not irritable. y Not tensed. y He discuss problem together with the family. Value-belief Pattern y Religion is important to them. y He wants good health. His family is important for his life. SUMMARY: The client, Rey Pecardal, is a 16 years old Filipino Male and the son of Vilma Pecardal and Raul Pecardal. His needs are being provided by his parents. He is currently studying. He does not exercise regularly and has a BMI that indicates normal. He does not have any visual and hearing problems.