INDIVIDUAL HEALTH CARE PROCESS A. BIOGRAPHICAL INFORMATION Name: Address: Contact No.

: Birthdate: Age: Birthplace: Race: Occupation: Usual source of health care: Date of Interview: B. CHIEF COMPLAINT

Sex: Religion: Marital Status:

C. PRESENT ILLNESS OR PRESENT HEALTH STATUS Clients Summary:

Usual Health: Onset Day: Manner: Duration: Quality: Quantity: Symptoms of CC: Alleviation Factors: D. PAST HISTORY 1. PAST ILLNESS Childhood Illness Injuries Hospitalization Operations Other major illness 2. ALLERGIES Environmental Ingestion Drug Other Allergy 3. IMMUNIZATION

( ) Gradual

( ) Sudden

4. HEALTH HABITS ( ) Alcohol ( ) Tobacco ( ) Drugs 5. MEDICATION TAKEN REGULARLY Practitioner Prescription By Self-prescription E. FAMILY HISTORY Fathers Side

( ) Coffee/ Tea

Mothers Side

F. PHYSICAL SYSTEM 1. GENERAL Usual State of Health General Appearance Recent Significant Gain or Loss of Weight Vital BP: ______mmHg Temp: ___ C PR: ____ bpm RR: ____ cpm Signs: Remarks: 2. SKIN ( ) Normal ( ) Cyanotic ( ) Warm TEMPERATURE COLOR ( ) Pallor ( ) Jaundice ( ) Cold ( ) Others ( ) Erythema ( ) Dry ( ) Clammy ( ) Smooth ( ) Scaly MOISTURE TEXTURE ( ) Sweaty ( ) Oily ( ) Rough ( ) Others ( ) Elastic/ ( ) Wrinkled HAIR TURGOR Mobile ( ) Non-elastic DISTRIBUTION Remarks: 3. NAILS ( ) Smooth ( ) Brittle NAIL PLATE ( ) Convex NAIL ( ) Ridged ( ) Thick SHAPE ( ) Clubbed CONDITION ( ) Rough ( ) Thin NAIL BED ( ) Pink ( ) Blue CAPILLARY ( ) Within 3 minutes COLOR ( ) Pale ( ) Others REFILL ( )Exceed 3 minutes Remarks: 4. HEAD AND FACE SKULL ( ) Smooth PROPORTIONATE ( ) Yes TO BODY CONTOUR ( ) Irregular ( ) No ( ) Easy ( ) White FACIAL ( ) Symmetrical ( ) Difficult SCALP ( ) Scaly MOVEMENT ( ) Assymetrical ( ) No Movement Remarks:

5. EYES EYES CONDITION EYELIDS

( ) Normal ( ) Strabismus ( ) Palpebral Fissure ( ) Effective Closure

EYEBROWS BLINK RESPONSE

( ) Thick ( ) None ( ) Thin ( ) Artificial ( ) Bilateral ( ) Unilateral ( ) Frequent ( ) Infrequent

EYEBALLS SCLERA REACTION TO LIGHT LACRIMAL APPARATUS Remarks: 6. EARS AURICLE COLOR TEXTURE & ELASTICITY EXTERNAL CANAL

( ) Symmetrical Bulbar: Palpebral: ( ) Asymmetrical CONJUNCTIVA ( ) Clear ( ) Pink ( ) Firm ( ) Unclear ( ) Pale ( ) Others ( ) White ( ) Reddish ( ) Equal PUPIL ( ) Icteric ( ) Others ( ) Unequal RIGHT: ( ) Brisk ( ) No reaction ( ) Sluggish LEFT: ( ) Brisk ( ) No reaction ( ) Sluggish ( ) Moist ( ) Excessive tearing ( ) No tears ( ) Symmetrical ( ) Asymmetrical ( ) Deformed ( ) Tender ( ) Scaly ( ) Flaky ( ) Lesions ( ) Responds to normal voice ( ) Whispered voice (2ft.)

( ) Normal ( ) Reddish ( ) Cyanosis ( ) Others

SYMMETRY & SIZE

HEARING DIFFICULTY Remarks: 7. NOSE AND SINUSES ( ) Normal tone EXTERNAL ( ) Flaring ( ) Discharge ( ) Pink ( ) Discharge MUCOSA ( ) Pale ( ) Others NASAL ( ) Moist ( ) Discharge CAVITY ( ) Dry ( ) Others Remarks:

( ) Elastic ( ) Tender PINNA ( ) Firm ( ) Non-tender Cerumen: ( ) Discharges ( ) Normal ( ) Swelling HEARING ( ) Impacted ( ) Redness ACUITY ( ) AD diff. ( ) AU diff. ( ) AS diff. ( ) Others

SEPTUM PATENCY SINUSES

( ) Midline ( ) Perforated ( ) Deviated ( ) Others ( ) Both ( ) Obstruction ( ) Patent ( ) Mass lesion ( ) Tender ( ) Others ( ) Non-tender

8. MOUTH AND TEETH ( ) Pink ( ) Dry ( ) Pink ( ) Moist LIPS ( ) Pale ( ) Symm MUCOSA ( ) Pale ( ) Lesion ( ) Cyanosis ( ) Asymm ( ) Cyanosis ( ) Others ( ) Midline Texture: ( ) Movable TONGUE ( ) Pink TONGUE Deviated: ( ) Smooth ( ) Atrophy COLOR ( ) Red ()R ()L ( ) Rough ( ) Others ( ) Complete ( ) Canes ( ) Pink ( ) Reddish TEETH GUMS ( ) Incomplete ( ) Dentures ( ) Pale ( ) Tender MOUTH ( ) Present SORES ( ) Absent Remarks: 9. PHARYNX/ THROAT ( ) Midline Deviated: POSTERIOR ( ) Normal ( ) Congested UVULA ( ) R ( ) L PHARYNX ( ) Inflamed ( ) Others ( ) Pink ( ) Reddish R inflamed: L inflamed: MUCOSA TONSILS ( ) Pale ( ) Others ( )Yes ( )No ( )Yes ( )No Remarks: 10. NECK AND NODES NECK ( ) Equal size ( ) Palpable LYMPH NODES MUSCLES ( ) Swelling ( ) Not palpable Deviated: ( ) Palpable TRACHEA ( ) Midline THYROID GLAND ()R ()L ( ) Not palpable Remarks: 11. CHEST AND LUNGS ( ) Regular ( ) Dyspnea ( ) Vesicular BREATHING BREATH ( ) Irregular ( ) Bronchial PATTERN SOUNDS ( ) Use Accessory Muscle ( ) Rales ( ) Wheezes ( ) Resonant ( ) Hyperresonant PERCUSSION ( ) Bronchovesicular ( ) Tympany ( ) Flat Remarks: G. SOCIOLOGICAL SYSTEM A. RELATIONSHIP WITH THE FAMILY AND SIGNIFICANT OTHERS Clients position in the family Persons with whom client lives Recent family crises changes B. ENVIRONMENT CONDITIONS Home Community Work C. OCCUPATIONAL HISTORY Jobs held Satisfaction with Employments

D. ECONOMIC STATUS AND RESOURCES Source of income Effects of illness on economic status E. EDUCATIONAL LEVEL Highest degree or grade attained Judgement of intellect relative to age F. DAILY PROFILE Rest-activity Pattern Social Activities Special Weekend Activities G. PATTERNS OF HEALTH CARE Dental Care Preventive Care Emergency Care H. BIOCHEMICAL APPRAISAL PATTERN FUNCTIONING 1. NUTRITION Food Likes Food Dislikes Food Allergies Fluid Intake Use of Vitamins Dietary Problems 2. ELIMINATION Bowel Urination Elimination Problems 3. PERSONAL HYGIENE Bathing Clothing 4. EXERCISE Type of Activity Frequency 5. SLEEP AND REST Number of hours of sleep Daily sleep & wake time Quality of sleep Sleeping disorders