NCMA121.HAs RLE Nursing Health History Format 1
NCMA121.HAs RLE Nursing Health History Format 1
NCMA121.HAs RLE Nursing Health History Format 1
I. BIOGRAPHICAL DATA
Name: Juan Miguel Garcia
Address: Sta. Rita, Pampanga
Birthdate: 09/16/2002 Age: 19 Occupation: N/A
Sex: Male Civil Status: Single Religion: Roman Catholic
Phone number: 09301943294
Provider of History: Px. Juan Miguel Garcia
Place of Birth: Porac, Pampanga
Language: Kapampangan, Tagalog, English
Educational Attainment: College Undergraduate
Chief Complain: Sore throat
Significant other/ Support Person: None
Admitting Diagnosis: Tonsillitis
Date of admission:
Date of Interview:
B. Childhood illnesses
The patient has no childhood illnesses.
C. Immunizations
The patient can no longer remember any immunizations at birth. However, the
patient took two doses of the Covid-19 Vaccine in the brand of Pfizer. He also
mentioned that he had his flu shot two weeks ago before the said interview.
D. Adult Illnesses
The patient recalls no adult illnesses.
F. Obstetrical History
None.
G. Accidents
The patient fell off a running car when he was four-years-old which resulted to his
minor surgery on his head.
H. Prolonged pain
None.
I. Medications
He has not taken any medications.
J. Allergies
The patient stated that he had no allergies.
V. FAMILY HEALTH HISTORY
Mr. Garcia said that his family on his father's side has a history of hypertension
and diabetes. No hereditary illnesses from the mother's side.
C. Eyes:
- No sign of poor eyesight.
D. Ears:
- Both auditory senses are working well.
G. Breasts:
- Normal.
I. Peripheral Vascular:
- Normal.
J. Abdomen:
- Normal.
K. Genitalia:
L. Anus/Rectum:
- Normal.
M. Musculoskeletal:
- Normal.
N. Neurologic:
- Normal.
F. SUBSTANCE USE
The patient drinks alcohol occasionally. He doesn't smoke and use any illegal
substances.
G. SOCIAL ACTIVITIES
He socializes with his friends by eating outside twice a week.
H. RELATIONSHIPS
The patient's relationship with his friends and family is good.
L. ENVIRONMENTAL
Note: Please refer to your laboratory manual about Collecting Subjective data: The
Interview and Health History which will serve as your guide to collect your data for
nursing health history. You should also use the table for your recording. (p7 – 12)
References:
Weber, J.R., Kelley, J.H, & Sprengel, A.D (2014). Lab Manual for Health Assessment in
Nursing (5th ed.). Wolter Kluwer Health/Lippincott Williams & Wilkins.