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7 Cards in this Set
- Front
- Back
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Examples of Biographic Data |
Clients: Name Age Address Sex Marital status Occupation Religious preferences Health care financing Usual source of medical care
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Chief Complaint or Reason for Visit |
This should be recorded in the clients own words. |
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History of present illness |
You may ask: When the symptoms started? (Are they sudden or gradual) How often the problem occurs? Give Exact location of distress Character of the compliant ( intensity of pain, quality of sputum) Factors that aggravate or alleviate the problem |
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Examples of Past History Information |
Illnesses (chickenpox, fever, hepatitis B) Immunization Allergies to drugs animals insects - how it occurs and how it's treated Accidents and injuries Hospitalization for serious illnesses Medications |
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Family history of illness |
To ascertain risk factors for diseases Age of siblings, parents grandparents and Thier current state of health If deceased (state cause of death) |
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Lifestyle |
Includes Personal habits ( coffee, tea, illegal and recreational drugs) Diet Sleep patterns Activities of daily living (ADL) Recreation & hobbies
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Social Data |
Includes Family relationships/ friendships Ethnic affiliation Educational history Occupational history Economic status Home and neighbourhood conditions |
