I.
BIOGRPHICAL DATA
Name of the Patient :
Gender :
Place of Residence :
Birthdate :
Place of birth:
Age :
Position in the Family:
Reason for seeking health care :
Date of Admission:
Attending Physician:
Chief Complaint/s: Diagnosis:
Informant (if applicable):
II.REACTION AND EXPECTATIONS TO ILLNESS, HOSPITALIZATION, DIAGNOSTIC STUDIES,
AND PERSONNEL
A. History of Present Illness
What are your concern rearding health?
How can I help you?
SIGNS AND SYMPTOMS
Character: how does it feel?
Onset: when did it began?
Location: can you point where is it? Doe it radiate?
Duration: how long it lasts?does it recur? (if recurring every when?)
Severity: how bad is it? From scale 1 to 10 where 10 is the most painful
Pattern: What makes it better? What makes it worse?
Associated Factor:Is there any other symptoms you have? Does it affect your activities of daily living?
B. Past Illness
Childhood Illnesses: Did you encounter any childhood illnesses?
Allergy: Do you have any allergies?(food, medicine, dust, animal danders,feathers)
Accident/Injuries: Did you ever get involved to an accident/injury?
Hospitalization: Have you gone confined on a hospital before?
Medication: By any chance, are you taking medicine? (if so how many times are you taking it?)
C. Obsteteric History
What is your age at your first menstral cycle?
When was your last menstral period?
What length and regularity of your mentruation?
How does it feel?
Did you undergo pregnancy?
D. Family History of Illness (maternal & paternal side)
What are your parents age?
Does your parents have illness?
What are your grand parents age?
Does your grand parents have illness?
How many uncles and aunts do you have? (maternal & paternal side)
Can you recall your aunts and uncles illnesses?
Does your parents have related cases/habits?
III.ACTIVITIES OF DAILY LIVING
A. Food and Fluid Intake
How many times do you eat in a day?
No. of cups of rice consumed per meal?
Do you eat snacks?
How many glasses of water you usually drink in a day?
What fluid do you usually take?
What type of food do you usually eat? Who buys, prepare and cook the food you eat?
When do you usually eat?
Where do you eat mostly at?
Do you have changes in usual eating pattern?
B. Elimination
How manny times do you usually void? What is it like?
Do you feel any pain when urinating? Does your urine have blood?
How many times do you usually defecate? What is it like?
Do you feel any pain when defecating? Does your stool have blood?
C. Sleep and Rest Pattern
What time do you usually wake up?
Are you getting enough rest?
How many hours do you usually sleep?
Do you have any sleeping problems?
What are your usual routine before sleeping?
When do you usually sleep?
D. Exercise
Do you have an exercise habit/s?
Do you exercise regularly?
IV.COMPETENCIES
A. Physical
Do you have the ability to perform your daily activities?
What type and level of activities do you usually do?
B. Emotional
Who/ what is the most important person/thing in your life?
Who is/are your support system?
How is your relationship with your family?
Who is the decision maker in your family?
What/who can make you upset?
Who/what is your greatest stressor in life?
C. Spiritual
What is your religion?
What is your spiritual and religious belief?
What is the meaning of life for you?
How well is your relationship with God? How strong do you believe in him?
What religious activities do you participate in?
How does religious belief affect your health?
D. Social
What do you usually do when you have free time?
With whom do you socialize frequently?
Do you think you have enough time to socialize?
Do you participate in community activities?
Do you have any organization membership?
E. Environmental
What do you think is the hazzard in your environment?
What is the type of neighborhood do you live in?
Is crime frequent in your area?
How far is community facilities and hospital in your house?
Integrated Head-to-Toe Assessment
Questionnaire Guide
Patient Information
Name: _______________________
Age: ___________
Sex: ☐ Male ☐ Female ☐ Other
Date of Assessment: ___________
Chief Complaint: ______________
History of Present Illness (HPI): ______________
Allergies: ☐ None ☐ Yes, specify: ______________
Medical History: (e.g., HTN, diabetes, asthma) ______________
Medications: ______________
Surgical History: ______________
Lifestyle (Smoking, Alcohol, Drug Use): ______________
I. General Appearance
Overall Appearance: ☐ Well-groomed ☐ Unkempt ☐ Distressed ☐ Other: ______________
Mental Status: ☐ Alert & Oriented (A&O x4) ☐ Confused ☐ Lethargic ☐ Unresponsive
Emotional State: ☐ Calm ☐ Anxious ☐ Depressed ☐ Agitated
Posture & Gait: ☐ Normal ☐ Unsteady ☐ Assistive Devices Used: __________
II. Vital Signs
Temperature: ______ °F/°C
Heart Rate: ______ bpm
Respiratory Rate: ______ breaths/min
Blood Pressure: ______ mmHg
Oxygen Saturation (SpO2): ______ %
Pain Level (0-10): ______________
III. Body Measurements
Height: ______ cm/in
Weight: ______ kg/lbs
BMI: ______
IV. Head-to-Toe Assessment (Integrated)
1. Skin, Hair, and Nails
Skin Color: ☐ Normal ☐ Pale ☐ Cyanotic ☐ Jaundiced
Skin Integrity: ☐ Intact ☐ Rash ☐ Lesions ☐ Ulcers
Temperature & Moisture: ☐ Warm ☐ Cool ☐ Clammy ☐ Dry
Turgor (Elasticity): ☐ Good ☐ Poor
Hair Condition: ☐ Normal ☐ Thinning ☐ Dandruff ☐ Lice
Nails: ☐ Normal ☐ Clubbing ☐ Brittle ☐ Cyanosis
2. Head and Face
Shape & Symmetry: ☐ Normal ☐ Asymmetrical ☐ Masses ☐ Lesions
Facial Movements: ☐ Normal ☐ Weakness ☐ Drooping
3. Eyes
Vision: ☐ Normal ☐ Blurred ☐ Double ☐ Glasses/Contacts
Pupil Size & Reaction: ☐ Equal & Reactive ☐ Unequal ☐ Non-reactive
Discharge/Redness: ☐ Yes ☐ No
Sclera Color: ☐ White ☐ Yellow (Jaundice)
4. Ears
Hearing: ☐ Normal ☐ Impaired ☐ Tinnitus
Drainage: ☐ Yes ☐ No
Ear Pain: ☐ Yes ☐ No
5. Nose and Sinuses
Nasal Congestion: ☐ Yes ☐ No
Nasal Discharge: ☐ Clear ☐ Yellow/Green ☐ Bloody
Tenderness Over Sinuses: ☐ Yes ☐ No
6. Mouth and Throat
Lips & Mucosa: ☐ Moist ☐ Dry ☐ Cracked ☐ Lesions
Teeth & Gums: ☐ Healthy ☐ Cavities ☐ Bleeding
Tongue & Throat: ☐ Normal ☐ Coated ☐ Redness ☐ Sore Throat
7. Neck
Trachea Position: ☐ Midline ☐ Deviated
Thyroid Enlargement: ☐ Yes ☐ No
Lymph Nodes: ☐ Non-palpable ☐ Enlarged ☐ Tender
8. Posterior & Anterior Thorax
Breathing Pattern: ☐ Normal ☐ Labored ☐ Shallow ☐ Deep
Lung Sounds: ☐ Clear ☐ Wheezing ☐ Crackles ☐ Diminished
Use of Accessory Muscles: ☐ Yes ☐ No
9. Heart
Heart Sounds: ☐ Normal ☐ Murmur ☐ Irregular
Peripheral Pulses (0-3+ Scale):
o Radial: ☐ Left ____ ☐ Right ____
o Pedal: ☐ Left ____ ☐ Right ____
Capillary Refill: ☐ <2 sec ☐ >2 sec
Edema: ☐ None ☐ Pitting (Grade: ____ )
10. Abdomen
Shape & Contour: ☐ Flat ☐ Rounded ☐ Distended
Bowel Sounds (Auscultation): ☐ Present ☐ Absent ☐ Hypoactive ☐ Hyperactive
Pain/Tenderness: ☐ Yes ☐ No
Last Bowel Movement: ________ ☐ Normal ☐ Constipation ☐ Diarrhea
11. Extremities (Upper and Lower)
11.1. Arms, Hands, and Fingers
Skin Condition: ☐ Normal ☐ Dry ☐ Ulcers
Muscle Strength (0-5 Scale): ☐ Normal ☐ Weakness
Sensation: ☐ Intact ☐ Diminished ☐ Numbness
11.2. Legs, Feet, and Toes
Skin Condition: ☐ Normal ☐ Ulcers ☐ Swelling
Capillary Refill: ☐ <2 sec ☐ >2 sec
Edema: ☐ None ☐ Pitting (Grade: ____ )
Foot Sensation: ☐ Intact ☐ Diminished ☐ Absent
12. Genitalia (Male and Female)
Male:
Testes: ☐ Normal ☐ Swollen ☐ Tender
Penis: ☐ Normal ☐ Lesions ☐ Discharge
Urination Issues: ☐ None ☐ Pain ☐ Dribbling
Female:
External Genitalia: ☐ Normal ☐ Lesions ☐ Swelling
Discharge: ☐ Normal ☐ Abnormal (Color: __________)
Menstrual History: ☐ Regular ☐ Irregular ☐ Absent
