patient history form (PLM format)

Patient’s Nursing History

Name of patient:

Hospital: Ward:

Demographic Data:

Address:

Birthday: age: sex: civil status:

Religion: Nationality:

Educational Attainment: Occupation:

Initial Data:

Mode of admission: emergency room

Vital signs on admission: BP: PR: RR: T=

General appearnce:

Dentures/ prothesis used:

Sensory motor deficits:

Psycho-social data:

Patient’s understanding of illness and hospitalization:

Patient’s expectation of present illness:

Family and Significant others:

Effects of hospitalization in the family:

Recreational activities/ hobbies/ special interest:

Specific Basic Needs or Problems:

Any pain or discomfort:

Measures/ intervention to relieve pain or discomfort: t

Assistance needed:

Sleeping patterns or problems:

Type of bath preferred and usual time:

Safety difficulty:

Is there any difficulty in walking? If yes, how did you manage?

Any special doctor’s order related to activity:

Ay difficulty in seeing or hearing:

Do you wear eyeglasses, contact lens, hearing aid?

Fluids and nutrition:

Fluid preferences:

Food preferences:

Appetite:

Condition of teeth:

Elimination:

Bowel frequency:

Bowel problems:

Bladder frequency:

Others:

Any breathing problems:

How do you manage:

Home medication:

Smoking:

Alcohol:

Nursing Impression:

Family History of Illness

• Diabetes Mellitus
• Pulmonary Tuberculosis
• Cancer
• Renal Disease
• Cardiac disorders

Past Medical History:

Example:

• 1968- PGH- appendectomy; s/p appendectomy
• 1982-PGH- stab wound RUQ of abdomen; s/p explore lap

History of Present Illness:

Example:

• 1mo PTA- patient have productive cough with whitish to yellowish phlegm accompanied by low garde fever. There is occasional Difficulty of breathing; didn’t seek medical assistance; took self-medication of Salbutamol tablet
• 1 wk PTA- Cough with whitish to yellowish phlegm is still visible; didn’t seek medical assistance; took self- medication of Amoxicillin tablet
• 1 day PTA- persistence of the above signs and symptoms w/ noted enhance severity of difficulty of breathing; still no consultation was done
• few hrs PTA- persistence of the above signs and symptoms with sever difficulty of breathing that lead in prompting consultation