Nursing Care Plan
History collection
-By Mr. S. Somorjit Singh, Professor, ANC
I. Biographical Data
Name: Age:
Address:
Date of Health History Sex: M /F
Hospital /IP No.
Ward: Bed No.
Date of Admission: Language Spoken and read
Information given by patient / Family Member/ Significant other:_________________________________________
If other than patient, Relationship with client:
Marital Status: Religion or spiritual practice:
Educational Status: Occupation: Income (monthly):
Sources of Health Care:
(Family physician, Private Hospital, PHC, Ayurveda, Homeopathy or other system of medicine)
Diagnosis:
Treatment under Dr.
II. Patient's reason for seeking admission
III. History of present illness
(Character, Onset, Location, Duration, Severity, Pattern, Associated factors)
Write in narrative form in order of occurrence including the points given in brackets
Details of medication I
taken for present symptoms:
IV. Past Health History
a. Past illness and treatment:
Problem at birth
Childhood illness
Immunization History
Adult illness (physical, mental and or psychological)
b. Previous hospitalization:
c.Surgeries:
d. Allergies (Food/Medication/others):
e. Any other history relevant to health:
f. Menstrual history (Female patient):
Menstruation: Regular/ Irregular, Cycle: __________________________days
Duration:___________ LMP:___________Age at Menarche: ___________Menopause:_________________
g. Past Obstetrical History:
Family history
Pedigree/
Genogram key
Female =
Male =
Patient =
point to patient Deceased =
() = cause of death
| .= Adoption (vertical)
Consanguinity=||
History of chronic illness (include Diabetes Mellitus, Hypertension, Coronary artery Diseases, Renal Diseases, Psychiatric illness, Cancer etc.):
History of any recent death in the family:
History of any communicable and hereditary disease in the family:
History of consanguinity:
Any other significant data:
Spiritual history:
VI. Lifestyle and health practices
a. Vegetarian / non-vegetarian/special diets/ other details (24 hours diet pattern):
b. Bowel and bladder habit:
c. Physical activities and exercises:
d. Work pattern (type, level of job satisfaction ion, work stress etc.):
e. Use of any substance, Medication (include if patient smokes, uses alcohol or drugs, chews betel leaves etc.)_
f. Sleeping and rest pattern:
g. Hobbies:
h. Relationship with family, friends, significant others:
i. Social activities for fun and relaxation:
j. Values, spirituality and religious activities:
k. Stressors in life and coping strategies:
VII. Environment History
a. Environmental hygiene:
b. Sources of Drinking water
c. Environmental Pollution
d. Disposal of excreta
e. Presence of files/ Mosquitoes/ Rodents/ etc.
f. Any other ______