St. John Colleges Chipeco Ave., Calamba City

Jun 21st, 2015
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Black Hills State University
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I. Biographic Data Name: Address: Age: Gender: Religious Affiliation: Marital Status: Occupation: Room and Bed #: Chief Complaint: Provisional Diagnosis: Attending Physician: II. Nursing History A. Past Health History 1. Childhood Illness 2. Immunizations

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St. John CollegesChipeco Ave., Calamba CityCase Study FormatI. Biographic DataName:Address:Age:Gender:Religious Affiliation:Marital Status:Occupation:Room and Bed #:Chief Complaint:Provisional Diagnosis:Attending Physician:II. Nursing HistoryA. Past Health History1. Childhood Illness2. Immunizations3. Allergies4. Accidents5. Hospitalizations6. Medications used or currently taken7. Foreign travel (when, length of stay)B. History of Present IllnessC. Family HistoryD. Obstetric History (for OB cases only)E. Development History (for pediatrics cases only)III. Patterns of FunctioningA. Psychological Health1. Coping Patterns2. Interaction Patterns3. Cognitive Patterns4. Self-Concept5. Emotional Patterns6. Sexuality7. Family Coping PatternsInterpretation:Analysis:B. Socio-Cultural Patterns1. Cultural Patterns2. Significant Relationships3. Recreation Patterns4. Environment5. EconomicInterpretation:Analysis:C. Spiritual Patterns1. Religious Beliefs and Practices2. Values and ValuingInterpretation:Analysis:IV. Activities of Daily LivingADLBefore HospitalizationDuring HospitalizationInterpretation and Analysis1. Nutrition

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