1 pts
2 pts
3 pts
Name, Gender, Address, DOB, race, ethnicity, marital status, religion(if pertinent), occupation, contact person, source of data, birthplace if pertinent.
Brief statement of the client's purpose for requesting the services of a health care provider
Present illness or problem as described by the patient
Focuses on the client's conditions (acute and chronic), medications teh patient is currently taking and allergies the client has experienced
Includes childhood ilnesses, surgeries, hospitalizations, immunizations, last examinations, obsetrical history(if applicable)
A family history of the patient's blood relatives, spouse and children traced back at least two generations.
Personal and social history including personal status, family and social relationships, diet/nutrition, functional ability, mental health,personal habits, health promotion activities, environment