Includes client’s name, address, age, sex, marital status, occupation, religious preference, health care financing, and usual source of medical care.
CHIEF COMPLAINT OR REASON FOR VISIT
The client’s answer to the question “What brought you to the hospital?” or “What is troubling you?” is expressed in the client’s own words
HISTORY OF PRESENT ILLNESS
This includes the onset of symptoms, when the symptoms started, if its development was sudden or gradual, severity and frequency of occurrence, the site or exact location of distress; the character of the complaint, its intensity or quality of discharge, sputum, etc.; activity of the client which may be involved in the development of the problem, phenomena or symptoms associated with the chief complaint, and the factors that aggravate or alleviate the problem.
This includes childhood illnesses, immunizations, allergies to drugs, animals, or other environmental agents, accidents and injuries, hospitalizations for serious illnesses, and medications currently used.
FAMILY HISTORY OF ILLNESS
This is to ascertain risk factors for diseases. Particular attention should be given to disorders such as diseases of the heart, tuberculosis, cancer, diabetes, hypertension, obesity, allergies, arthritis, bleeding, alcoholism, and any mental disorders.
This includes personal habits, diet, sleep/ rest patterns, activities of daily living, instrumental activities of daily living, recreation or hobbies.
This pertains to quality of family relationships/friendships, ethnic affiliation, educational background, occupational history, economic status, home and neighborhood conditions.
These are major stressors experienced by the client and their perception of them, how they cope up with these stressors, their communication to relay appropriate emotion.
PATTERNS OF HEALTH CARE
Includes all the health care resources that the client is currently using and has used in the past.