STUDENT IDENTIFICATION DATA
Name Of the Institute: Tata memorial hospital College of nursing
Name of the Student: Ranjita Minj
Batch:
Name Of Clinical area:
Date of Selection of Patient:
Supervisor : Madam Prathepa Jagdish.
Submitted to : Madam Prathepa Jagdish.
HISTORY COLLECTION
PATIENT PROFILE
I. History Collection:
Name:
Age :
Sex :
Education :
Occupation :
Religion :
Marital Status :
Husband's Name:
Wife's Name :
Address :
Date of Admission :
Diagnosis:
Ward Name
I.P. No:
Bed No:
III. Chief complaints:
IV. History of Health status:
(a) Present Medical History:
(b) Past Medical History:
(c) Present Surgical History:
(d) Present Surgical History:
V. FAMILY HISTORY:
Family tree:
S. Name of family Member Age Sex Relationship Occupation Health Remarks
No status
VI. Personal History
(a) Habits
(b) Sleep
(c) Nutrition
(d) Elimination Pattern
VII. Socio Economic Status
(a) Housing
(b) Ventilation
(c) Electricity
(d) Water supply
PHYSICAL ASSESSMENT/EXAMINATION
Vital signs:
Temperature:
Pulse:
Resp. Rate:
B.P:
General Appearance
Nourishment:
Body build:
Health:
Activity:
Consciousness:
Look:
Body curves:
Movement:
Height:
Weight:
Skin Colour :
Skin
Colour:
Texture:
Temperature:
Lesions:
Rashes:
Lumps:
Itching:
Dryness:
Moles:
Head:
Size:
Shape:
Hair & Scalp/ Skull/ face:
Colour:
Distribution:
Hair loss:
Dandruff:
Lice:
Healthy:
Eyes:
Vision/Visual Acuity:
Eyeballs:
Conjunctiva:
Sclera:
Cornea and Iris:
Pupils:
Fundus:
Eye muscles:
Eye brows:
Eye lashes:
Lens:
Glasses:
Discharge:
Pain:
Itching:
Ears
Hearing:
Ear Canals:
Ear Drum:
External Ear:
Tympanic Membrane:
Pain:
Itching:
Ringing:
Ringing:
Vertigo:
Nose & Sinuses
Deviated nasal septum:
External Nares:
Nostrils:
Discharge:
Allergies:
Frequent colds:
Obstruction:
Pain:
Epistaxis:
Mouth & throat:
Tongue:
Lesions:
Lips:
Bleeding:
Tooth decay:
Dental care:
Odor:
Throat & Pharynx:
Mucus Membrane:
Gums:
Neck:
Stiffness:
Limited motion:
Lymph nodes:
Swelling:
Pain:
Thyroid Gland:
Swallowing Reflex:
Cervical Spine:
Muscles of Back (Neck):
Respiratory System
H/O Smoking:
Sputum (Colour):
Asthma:
Wheezing:
Haemoptysis:
Cough:
Shortness of Breath:
Inspection:
Palpation:
Percussion:
Auscultation:
II. Cardio Vascular System
H/O Hypertension:
Varicose veins:
Dyspnoea:
Orthopnoea:
Chest pain:
Palpitation:
Claudication:
Heart sound:
Pulse:
Heart beat:
Inspection:
Palpation:
Percussion:
Auscultation:
III. Gastro Intestinal System:
Shape & Symmetry:
Abdominal girth:
Pain:
Abdominal distension:
Artificial Openings:
Anorexia:
Diarrhoea:
Nausea:
Constipation:
Vomiting:
III. Gastro Intestinal System:
Shape & Symmetry:
Abdominal girth:
Pain:
Abdominal distension:
Artificial Openings:
Anorexia:
Diarrhea:
Nausea:
Constipation:
Vomiting:
Hemetemes:
Food intolerance:
Bowel sounds:
Abdomen:
Soft & Tender:
Inspection:
Palpation:
Percussion::
Auscultation:
IV. Genito urinary system
Nocturia:
Dysuria:
Incontinence:
Infection:
Frequency:
H/O Illness (or) surgery:
Inspection:
Palpation:
Percussion:
Auscultation:
V. Genito Reproductive system:
Female
Manses:
Menarche:
Cycle:
Duration:
No. of Pregnancies:
Menopause:
Vaginal Discharge:
H/O STD:
Male:
Pain:
Soreness:
Discharge:
H/O STD's:
Swelling:
VI. Musculo-skeletal system:
Posture:
Muscular pain/cramps:
Pain:
Swelling:
Upper extremities:
Range of motion:
Colour of extremities:
Any deformities:
Lower extremities:
Range of motion:
Colour of extremities:
Any deformities:
Inspection;
Palpation:
Percussion:
Auscultation:
VII. Integumentary system:
Color
Texture:
Moisture:
Dryness:
Bleeding:
Discharge:
Palpation:
Percussion:
Auscultation:
Discharge:
Infection:
VIII. Hematological System
Hb%:
Bleeding tendencies:
Any blood transfusions:
IX. Neurological system
Level of consciousness:
Activity:
Dizziness:
Posture & gait:
Tremors (or) seizures:
Sensation of pain:
Mental status:
Motor function:
Sensory function:
Cranial nerves: