CLIENT’S INFORMATION SHEET

Be it known to all concerned that the information below will be treated with privacy and confidentiality.

NAME: (Optional) DATE:

ADDRESS: BIRTHDATE: AGE: CONTACT No.: (Optional) CIVIL STATUS: PHILHEALTH MEMBER:YESNO
ATTENDING PHYSICIAN: (Optional)
PEDIATRICIAN: (Optional)
BIRTHING FACILITY:

MENSTRUAL HISTORY OBSTETRICAL

MENARCH: LMP: G PSCORING
T P A L

Please detail all pregnancies in order.

Your periods occur every days and last for days.
DATE OF AOG AT THE TIME OF TYPE OF PLACE OF
# GENDER ANESTHESIA
DELIVERY DELIVERY DELIVERY DELIVERY

ANY PROBLEM WITH YOUR PERIODS? NO

YES IRRREGULA
HEAVY FLOW CLOT
R
PAIN/ S
DISCHARG
CRAMPING
E
BLEEDING BETWEEN PERIODS
OTHERS: EDD: FETAL BACK:
AOG: PRESENTATIO
FHT: N:
FUNDIC
HEIGHT:
GYNECOLOGICAL HISTORY CONTRACEPTIVE HISTORY
Have you had any of the following? (Check ALL that apply)
Are you currently sexually active?
YES NO NEVER BEEN
Abnormal Pap Smear Ovarian cyst
Infertility Chronic Pelvic Pain
Previously used Birth control method (Check ALL that apply)
PID Genital Warts
Birth Control Pill
Recurrent vaginitis Pain in Intercourse
Condoms
Urinary Incontinence Recurrent Miscarriage Diaphragms
Breast pain UTI DepoProvera
Endometriosis Uterine Fibroids IUD
Spermicide
STD:
Other:
None of the above
No previous birth control

Any problems with previous method? NO

YES:
PREVENTIVE CARE HISTORY
VACCINATIONS (YEAR)
LAST PAP SMEAR DATE: NORMAL ABNORMAL FLU SHOT
LAST MAMMOGRAM DATE: NORMAL ABNORMAL TDAP VACCINE
LAST CHOLESTEROL TEST DATE: NORMAL ABNORMAL TETANUS-DIPHTERIA
LAST CBC TEST DATE: NORMAL ABNORMAL VARICELLA
LAST BP SCREENING: NORMAL ABNORMAL VACCINE HEPATITIS
LAST BONE DENSITY TEST: NORMAL ABNORMAL VACCINE MMR
LAST DIABETES SCREENING: NORMAL ABNORMAL VACCINE

SURGICAL HISTORY (Please list all surgical procedures) NONE

SURGERY: DATE:
SURGERY: DATE:
SURGERY: DATE:
SURGERY: DATE:
SURGERY: DATE:

CURRENT MEDICATION HISTORY (Please include current prescriptions and medications ONLY)

DRUG NAME: DOSE:

DRUG NAME: DOSE:
DRUG NAME: DOSE:
DRUG NAME: DOSE:
DRUG NAME: DOSE:

ALLERGY HISTORY (Please list all surgical procedures) NONE

ALLERGY: ALLERGY: ALLERGY: ALLERGY:

REACTION:
ALLERGY: REACTION:

REACTION:
REACTION:
REACTION:

SOCIAL AND LIFESTYLE HISTORY

CIGARETTE SMOKER ALCOHOL USE CAFFEINE USE DOMESTIC ABUSE REGULAR EXERCISE MONTHLY BREAST EXAM
NEVER NO NOFORMER
NO NO YES
NO NOCURRENT-AMT/DAY
HAVE YOU HAD CHICKENPOX
NO YES YES YES YES
IF YES,
YES YES
AMT/WK IF YES, AMT/DAY
STREET DRUGS/MARIJUANA USE
NO

IF YES, CURRENT or PAST

TYPE: AMT/WK

DO YOU HAVE A HEALTH CARE DIRECTIVE (LIVING WILL) YES

PAST MEDICAL HISTORY Indicate Relationship
EXPERIENCING TODAY/RECENTLY
ANEMIA SELF FAMILY →
Review of Systems
ANXIETY SELF FAMILY →
FEVER YES NO
ASTHMA SELF FAMILY →
CHILLS YES NO
BLOOD CLOTTING DISORDER SELF FAMILY → SWEATS YES NO
CANCER; BREAST SELF FAMILY → CONSTITUTIONAL WEIGHT LOSS YES NO

CANCER; CERVICAL SELF FAMILY → WEIGHT GAIN YES NO

FATIGUE YES NO
CANCER; COLON SELF FAMILY →
EYES IMPAIRED VISION YES NO
CANCER; OVARIAN SELF FAMILY →
HEAD, EARS, NOSE, & HEADACHES YES NO
CANCER; SKIN-TYPE: SELF FAMILY →
THROAT SINUS CONGESTION YES NO
CANCER; UTERINE SELF FAMILY →
LUMPS YES NO
CANCER; OTHER: SELF FAMILY → TENDERNESS YES NO
BREAST
CARDIAC ARRYTHMIA SELF FAMILY → SWELLING YES NO

CORONARY ARTERY DISEASE SELF FAMILY → NIPPLE DISCHARGE YES NO

CHEST PAIN YES NO
CROHN’S DISEASE SELF FAMILY →
CARDIOVASCULAR
LOSS OF CONSCIOUSNESS YES NO
CYSTIC FIBROSIS SELF FAMILY →
SHORTNESS OF BREATH YES NO
DEEP VEIN THROMBOSIS (DVT) SELF FAMILY →
RESPIRATORY WHEEZING YES NO
DEPRESSION SELF FAMILY →
COUGH YES NO
DIABETES TYPE: SELF FAMILY → NAUSEA YES NO
EATING DISORDER: SELF FAMILY → VOMITING YES NO

GASTRIC ULCER SELF FAMILY → GASTROINTESTINAL DIARRHEA YES NO

CONSTIPATION YES NO
GERD SELF FAMILY →
BLOOD IN STOOLS YES NO
GESTATIONAL DIABETES SELF FAMILY →
URINARY URGENCY YES NO
HEPATITIS– TYPE: SELF FAMILY →
URINARY FREQUENCY YES NO
HYPERLIPIDEMIA SELF FAMILY → GENITOURINARY
URINARY INCONTINENCE YES NO
HYPERTENSION SELF FAMILY → BLOOD IN URINE YES NO

IRRITABLE BOWEL SYNDROME SELF FAMILY → RASH YES NO

KIDNEY STONES SELF FAMILY → INTEGUMENTARY CHANGE IN MOLES, LESION YES NO

CHANGE IN HAIR GROWTH/LOSS YES NO

LUPUS SELF FAMILY →
MUSCULAR WEAKNESS YES NO
MIGRAINES SELF FAMILY →
NEUROLOGIC INCOORDINATION YES NO
MULTIPLE SCLEROSIS SELF FAMILY →
TINGLING OR NUMBNESS YES NO
OSTEOPOROSIS SELF FAMILY →
JOINT PAIN YES NO
MUSCULOSKELETAL
PARKINSON’S DISEASE SELF FAMILY → MUSCLE PAIN YES NO
PULMONARY EMBOLISM SELF FAMILY → EXCESSIVE THIRST YES NO

RHEUMATOID ARTHRITIS SELF FAMILY → ENDOCRINE EXCESSIVE URINATION YES NO

TEMPERATURE INTOLERANCE YES NO
SCOLIOSIS SELF FAMILY →
ANXIETY YES NO
SEIZURES SELF FAMILY →
DEPRESSION YES NO
SICKLE-CELL DISEASE SELF FAMILY →
PSYCHIATRIC FEELING CONFUSED YES NO
SLEEP APNEA/DISORDER SELF FAMILY →
DIFFICULTY SLEEPING YES NO
STROKE SELF FAMILY → EXCESSSIVE ANGER YES NO
THYROID DISORDER-TYPE: SELF FAMILY → EASY BLEEDING YES NO

TUBERCULOSIS SELF FAMILY → HEME-LYMPH EASY BRUISING YES NO

SWOLLEN LYMPH GLANDS YES NO
ULCERATIVE COLITIS SELF FAMILY →
SINUS ALLERGY SYMPTOMS YES NO
Other Medical History we should know about: ALLERGIC-IMMUNOLOGIC
FREQUENT ILLNESSES YES NO
ARE THERE ANY OTHER PROBLEMS THAT ARE IMPORTANT TO YOU TODAY?
NO YES
 HEALTH TEACHING
List down 5 health teachings pertaining to the following
topics listed below. Health Teaching should be part of your
Video Recording.

PREGNANCY

BREASTFEEDING

NEWBORN BELIEFS
This is to certify that the about information is true and AND onMISCONCEPTIONS
correct based the knowledge of my
client.
Client’s information shall be treated with privacy and confidentiality.
FOR LEARNING PURPOSES ONLY

STUDENT NURSE
SIGNATURE
JOSELITO O. FILLE, RN, MAN

YEAR AND NCM 107 PROFESSOR

SECTION