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The document outlines a comprehensive patient identification form that includes personal details, family history, and various health-related histories. It also lists vital signs with normal ranges for blood pressure, pulse, respiration, oxygen saturation, temperature, and blood sugar levels. This structured format is designed for collecting essential health information for medical assessment.

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0 views

Format

The document outlines a comprehensive patient identification form that includes personal details, family history, and various health-related histories. It also lists vital signs with normal ranges for blood pressure, pulse, respiration, oxygen saturation, temperature, and blood sugar levels. This structured format is designed for collecting essential health information for medical assessment.

Uploaded by

sports news
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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IDENTIFICATION DATA

• Name of the Client :


• Age/Sex :
• Address :
• Education :
• Occupation :
• Religion :
• Marital Status :
• Annual Income :
• Blood Group :
• Contact no. :

HUSBAND /WIFE HISTORY:

• Head of the Family :


• Age/Sex :
• Education :
• Occupation :
• Income :

HISTORY COLLECTION

PRESENT COMPLAINT:

PRESENT HISTORY OF ILLNESS:

PAST MEDICAL HEALTH HISTORY:

SURGICAL HISTORY:
FAMILY HISTORY:

SOCIO-ECONOMICAL STATUS:

PERSONAL HISTORY:

NUTRITIONAL HISTORY:

PSYCHOLOGICAL HISTORY:

VITAL SIGNS :

SR VITAL SIGN PATIENT NORMAL REMARK


NO. VALUE VALUE

1. BLOOD PRESSURE 120/80


Mmhg

2. PULSE 72b/m

3. RESPIRATION 18-20/m

4. OXYGEN SATURATION 97%-100%

5. TEMPERATURE 37.6 C

6. BLOOD SUGAR LEVEL 80-110 mg/dl

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