HISTORY TAKING
(A) IDENTIFICATION DATA OF PATIENT
NAME:
AGE:
SEX:
ADDRESS:
RELIGION:
OCCUPATION:
EDUCATIONAL QUALIFICATION:
MARITAL STATUS:
DIAGNOSIS:
HOSPITAL NUMBER:
WARD:
BED NUMBER:
DATE OF ADMISSION:
MEDICAL DIAGNOSIS:
SURGICAL DIAGNOSIS:
DATE OF OPERATION:
NAME OF ATTENDING DOCTOR:
DATE OF DISCHARGE:
DURATION OF STUDY:
(B) CHIEF COMPLAINTS:
(C) HISTORY OF PRESENT ILLNESS:
O- Onset
L-Location
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D-Duration
C-Characteristics
A-Alleviating Factors
A-Associated Factors
R-Radiation
S-Severity
F- Frequency
P- Progression
(D) HISTORY OF PAST ILLNESS: (WHEN/WHY/WHY/MEDICATION)
PAST MEDICAL HISTORY:
PAST SURGICAL HISTORY:
(E) PERSONAL HISTORY:
SLEEP PATTERN:
BOWEL PATTERN:
BLADDER PATTERN:
HYGIENE:
DIETARY HABIT:
HISTORY OFANY ALLERGY:
HISTORY OF BLOOD TRANSFUSION:
LIFESTYLE PATTERN:
HISTORY OF SUBSTANCE ABUSE:
ACTIVITIES OF DAILY LIVING:
HOBBIES:
HISTORY OF MENTAL ILLNESS:
SPIRITUAL HISTORY:
2
RECENT TRAVEL:
(F) MENSTRUAL HISTORY:
AGE OF MENARCHY-
PATTERN OF BLOOD FLOW-
PAIN DURING MENSTRUATION-
AGE DURING MENOPAUSE-
(G) FAMILY HISTORY:
TYPE OF FAMILY:
NUMBER OF FAMILY MEMBERS:
FAMILY STRUCTURE:
SL. NAME OF THE AGE/ RELATIONSHIP EDUCATION OCCUPATION HEALTH
NO FAMILY MEMBER SEX WITH PATIENT STATUS
GENOGRAM:
KEY FACTOR
MALE
FEMALE
PATIENT
DEATH
DEATH
3
(H) SOCIO ECONOMIC STATUS:
HOUSING CONDITION:
WASTE DISPOSAL FACILITIES:
WATER AND SANITATION FACILITIES:
ELECTRICITY SUPPLIES:
SOURCE OF INCOME:
TOTAL EARNING IN THE FAMILY:
RELATIONSHIP WITH RELATIVES AND NEIGHBOURS:
PHYSICAL EXAMINATION
4
(A) GCS SCORE:
EYE RESPONSE-
VERBAL RESPONSE-
MOTOR RESPONSE-
TOTAL-
(B) GENERAL INFORMATION:
APPEARANCE (Ectomorphic/ Mesomorphic/Endomorphic):
SENSORIUM (Alter/Drowsy/Confused/Semiconscious/Comatose/ Intact):
POSTURE(Healthy Posture/ Kyphosis/ Lordosis/ Flat Back/ Forward Head):
GAIT(Spastic Gait/Scissors Gait/Steppage Gait/Waddling Gait/Propulsive Gait):
EMOTIONAL STATE (Anxious/ Calm/Angry/Cooperative/Fearful/Restless/Withdrawn):
SPEECH(Relevant/Irrelevant/Slurred/Aphasia):
HEIGHT :
WEIGHT:
BMI:
(C) VITAL SIGNS:
Vital signs Day 1st Day 2nd Day 3rd Day 4th Day 5th
(temperature,
pulse,
respiration, blood
pressure, pain)
(D) SKIN:
LESION (Blisters/Macules/Nodules/Papules/Pustules/Rashes/Wheals):
COLOUR(Pale/ Fair/Beige/ Naturally Brown/ Very Dark Brown/Black):
TEXTURE (Normal/Oily/Dry/Dehydrated/Combination Type/Acne-Prone/Sensitive/Mature):
TURGOR(Intact/ Decrease):
5
CYANOSIS (Peripheral/Central) :
TEMPERATURE (Afebrile/ Febrile):
(E) HAIR:
COLOUR (Black/Brown/Blond/White/Gray):
HYGIENE (OF HAIR AND SCALP):
DISTRIBUTION(Equally distributed/ Vellus hair/ Terminal hair):
(F) NAILS:
COLOUR(Pink/Pale/Yellowish/ Dark Brown):
HYGIENE:
SHAPE(Square/Round/Oval/Squoval/Pointed):
CAPPILARY REFILL TIME (Adults refill in less than 3 seconds,Older adults often take more
than 3 seconds but less than 5 seconds):
(G) EYES:
VISION (20/20 vision is normal vision acuity):
POSITION (eyes sit in bony cavities called the orbits, in the skull):
COLOUR OF CONJUNCTIVA(Pink/Pale):
COLOUR OF SCLERA(White/ yellowish/Pale):
INFECTION :
PUPIL(Reactive to light/ Non-reactive):
EYEBROWS (Tail arch/Centre arch/High arch/Minimal arch/Straight brows/Tapered
brows/Rounded brows/Short and thick):
EYELIDS(Monolids/Double Eyelids/Hooded Eyelids):
DISCHARGE,if present :
(H) NOSE:
6
NASAL DEVIATION (Type I ,normal—naso septal angle less than 5°/Type II ,mild—naso
septal angle from 5° to 10°/Type III ,moderate—naso septal angle from 10° to 15°/Type
IV ,severe—naso septal angle more than 15°):
SMELL (Intact/ Pungent/ Absent):
DISCHARGE:
(I) EARS:
HEARING:
ALIGNMENT OF PINNA (Intact/Deformed):
HYGIENE:
(J) ORAL CAVITY:
HALITOSIS (Present/ Absent):
ANGULAR STOMATITIS (Present/ Absent):
GUMS (Pink and Firm/ Pale/ Gingivitis):
ORAL MUCOSA (Pink/Pale/ Slightly brown/ Bluish):
TEETH(Clean/ Plaque/Loose/Cavities):
TONGUE (Clean/Coated):
LIPS ( Pink and smooth/ Dry/ Chapped/ Pale white):
(K) NECK:
JEGULAR VEIN DISTENTION (Present/Absent):
MOVEMENT (Intact/ Restricted):
LYMPH NODES (Palpable/ Nonpalpable):
(L) RESPIRATORY SYSTEM:
INSPECTION –
SHAPE AND SYMMETRY:
MOVEMENT(Unilateral/Bilateral/ Absent):
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RATE, RHYTHM, DEPTH OF RESPIRATION(Normal/ Dyspnea/ Orthopnea/ Paroxysmal
Nocturnal Dyspnea/ tachypnea/ bradypnea):
AIR ENTRY (Bilaterally equal/ Diminished specify Right or Left lung):
INJURY/SCARS:
COUGH(Present;Moist or Dry/Absent):
OXYGEN ON FLOW(L/min):
CHEST DRAINS(Left pleural/ right pleural/Mediastinal):
PALPATION –
PERCURSION –
AUSCULTATION –
BREATH SOUNDS(Normal; Broncho vesicular sound/Rales/ Ronchi/ Wheeze):
(M) CARDIOVASCULAR SYSTEM:
HEART SOUNDS(S1/S2/S3/S4/Murmur/ any other):
RHYTHM (Normal/ tachyarrythmia/ bradyarrthmia):
PERIPHERAL PULSE (Present/ Feeble/Absent):
Radial-
Poplitial-
Post.Tibial-
Dorsalis Pedis-
CHEST PAIN (Present/ Absent):
PACE MAKER (Permanent/ Temporary/ Absent):
(N) GASTRO-INTESTINAL SYSTEM:
INSPECTION –
SHAPE OF ABDOMEN (Flat/Scaphoid/Protuberant/Distended):
SIZE OF ABDOMEN:
8
VISIBLE VEINS:
SCARS:
PERISTALSIS(Present/ Absent):
NPO(NIL PER ORALLY) OR NBM (NOTHING BY MOUTH):
NUTRITIONAL ROUTE(Oral/ Tube feeding/ Parenteral):
PALPATION –
PRESENCE OF MASS:
ABDOMINAL DISTENSION:
PERCURSION –
ASCITIS (Present/ Absent):
AUSCULTATION –
BOWEL SOUNDS (Normal bowel sounds/Hypoactive bowel sounds/Hyperactive):
(O) GENITALIA:
MALE/ FEMALE:
(P) BACK:
SPINAL CORD ; cervical, thoracic, lumbar and sacral (Intact/ Injured):
SPINAL TENDERNESS (Present/ Absent):
PRESSURE ULCER (Stage I/Stage II/Stage III/Stage IV) ;(Present/ Absent):
PALPABLE MASS (Present/ Absent):
(Q) EXTREMITIES:
SHAPE (Long/ Short/ Symmetrical/ Asymmetrical):
NUMBNESS(Present/ Absent):
USE OF PROSTHETIC DEVICE:
USE OF SUPPORTIVE DEVICE:
(R) MUSCULO SKELETAL SYSTEM:
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JOINTS ( Mobile/ Stiff/ Painful/ Contractures/Intact):
RANGE OF MOTION(Intact/ Diminished/ Need assistance):
SWELLING(Present/ Absent):
STRENGTH:
AMBULATORY STATUS(Intact / Confined to bed):
(S) NEUROMUSCULAR ASSESSMENT:
PAIN:
PALLOR:
PARASTHESIA:
PARALYSIS:
PULSE:
(T) INVASIVE LINES AND IV FLUIDS:
CENTRAL LINE; site and condition-
PERIPHERAL LINE; VIP score-
ANY OTHER LINES-
(U) INCISIONAL WOUND (Healthy/ Oozing/ Gaping):
PAIN; every 2 hourly:
DRESSING :
ANY OTHER WOUND; site , size and condition-
(V) INVESTIGATION REPORT:
HAEMATOLOGY REPORT
SL INVESTIGATION / PATIENT’S NORMAL VALUE REMARKS
NO. TEST NAME VALUE
BIOCHEMISTRY REPORT
10
SL TEST NAME PATIENT’S NORMAL VALUE REMARKS
NO. VALUE
(W) MEDICATION:
SL NO. DRUG NAME DOSE/ MECHANISM INDICATION SIDE CONTRA NURSING
(BRAND NAME, ROUTE/ OF ACTION EFFECTS INDICATION RESPONSIBILI
PHARMACEUTI DURATI TIES
CAL NAME, ON
FUNCTIONAL
CLASS)
(X) NURSING CARE PLAN:
SL NURSING NURSING GOAL PLAN NURSING RATIONALE EVALUATION
NO. ASSESSMENT DIAGNOSIS OF INTERVENTION
ACTION
SUBJECTIVE
DATA
OBJECTIVE
DATA
(Y) PROGNOSIS REPORT:
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