HEALTH HISTORY

A. BIOGRAPHIC DATA

The client’s name is JCP, a 17 years old, single, female, and lives at 1037 J. B. Miguel St. Bambang, Pasig, City.
She is a Roman Catholic although she was born on October 10, 1989 in the Kingdom of Saudi Arabia. The client is
a pure Filipino citizen who can speak Filipino as well as English. She is currently a 2nd year college student at Far
Eastern University taking up BS Nursing. Her parents and guardians are her source of finances with regards to
health care and medical needs.

B. PRESENT HEALTH HISTORY

The client stated that she is not experiencing any problems or disease at present times. She also said that she rarely
acquire a disease.

C. PAST HEALTH HISTORY

The client had chicken pox when she was 7 years old and received medical treatments but she doesn’t anymore
remember the medications that were given to her. She said that according to her mother, she had received OPV,
DPT, and BCG immunizations during childhood. The client has occasional rashes on the chest due to hot weather.
Her dermatologist prescribed her Stiemycin as a treatment. She also applies acne gel (applied every other day),
tretinoin cream and bleaching cream (both applied every other night) on her face in order to treat pimples. So far,
the client has not experienced any side effects while using the said drugs/medications.

D. FAMILY HISTORY OF ILLNESS

The client’s father, who’s 38 years old, has diabetes while her mother, who’s 37 years old, has asthma. The
grandfather of the client on her mother side, still living and is 81 years old, has tuberculosis while her grandmother
still on the mother side is 70 years old and has arthritis. The client’s two other younger siblings, whose ages are 11
and 14, have currently no diseases inherited from their parents. The client also said that she at present, has no
diseases.

3 DAYS DIET RECALL

Name of the client: Jenileen Carlette T. Peronilla

The client conducts bowel elimination everyday in the morning after waking up or sometimes at night before
bathing. Her stool usually is a formed one that is brownish in color and has regular diameter of not less than 1 inch.
She does not experience pain or discomfort. The client also conducts urine elimination at least 3 times a day with
varying time. Her urine is often yellowish to whitish color and is not aromatic in smell but does not have a strong
foul odor. She also does not experience pain or discomfort. She tends to perspire quickly especially of doing
activities that require much movement such as dancing. She does not have a strong smell or body odor.

H. ACTIVITY - EXERCISE PATTERN

The client’s usual activities include going to school and studying. She is also a member of the FEU Dance Troupe
adds on to her being happy and content. She engages in light exercise and dance workshops. She is satisfied with
the amount of exercise that she gets which is having it 3 times a week with duration of 30 minutes per exercise. She
noticed that her alertness level increased and makes her feel energized. Inside the classroom, the usual activities that
she does are to just sit around and listen to the professor in front. The activities of the client that needs to be done
are going to school, attending dance troupe rehearsals, having I shod exercise (stretching) and engaging in
household chores. The client commonly has sufficient energy to do all the mentioned tasks. She brought up that she
has a desire to do certain extreme sports like bungee jumping and rappelling but worries that she might not have the
time, not really the energy, to accomplish my desires. The client is also able to do activities of daily living (i.e.
bathing, toileting, grooming, etc.) by herself. She spends her spare time by watching television, listening to music,
dancing, or playing board games. She is satisfied with the way on how she spends her leisure time. These activities
keep the client from boredom and are exercising her brain capacity. Though the client said that she is satisfied with
the amount of activities that she’s getting, she proclaimed that she is not managing her time very well. She does
things whenever she likes doing it.

[1] CLIENT’S DAILY ACTIVITIES

The client sleeps for about 3-4 hours every night ever since second year in college started because of lots of
requirements asked from the students by all subjects. Usually, she sleeps at 2am and wakes up at 4am. The sleep is
not continuous, does wake up in the middle of the sleep. The client is not satisfied with the amount of sleep because
it lessens her body’s time to recuperate from all the stress that she accumulated the entire day. The client does not
feel refreshed when she wakes up because of inadequate amount of sleep. The client’s sleeping environment is
comfortable. She shares the bed with her aunt. She is not really particular on the number of pillows beside her. She
is sometimes more comfortable without a pillow on her head and rather prefer to put a pillow on her lower back
because she wants to improve its curve. The client’s desired sleeping environment is a bedroom of her own. The
client drinks a glass of water before going to bed and makes sure that she has already voided. She does not have
problems falling asleep. The client does not require any help falling asleep including back rubs or massages or
sleeping pills. The client does not take naps. For relaxation, the client watches TV, reads something, surfs the net,
etc. She finds them helpful when relaxing.

J. COGNITIVE - PERCEPTUAL PATTERN

The client’s hearing is normal for both ears. Her Weber’s test is normal that she can hear vibrations equally on both
ears and her Rinne’s test also indicates that her air-conducted hearing is greater than the bone-conducted hearing
which is normal. No changes had occurred lately. The client has astigmatism and her visual acuity is 20/40. She
used to wear glasses but it got broken and she is still looking for someone who can fix it. Her last visit to the doctor
was last year. The client’s memory is good which means that both her shod term memory works as well as her long
term memory. For her, the easiest way to learn is to have someone demonstrate the topic in a much simpler
approach. The client does not experience learning difficulties and prefers a teacher to just be the one to discuss the
topic. The client does not have any problems speaking, reading or writing. No changes in smell or taste. The client
is doing well in school.

K. SELF-PERCEPTION - SELF-CONCEPT PATTERN

The client described herself as an optimistic individual, jovial, and easy to deal with. She also added that she is a
great dancer and also does well in school. She feels good about herself most of the time and is happy about herself.
No physical alterations in her body. No changes about the way she feels about herself. The client thinks that she is
just as equal with other people because there are traits, features and characteristics that she have that other don’t
have and vice versa. She expressed her thought about other people more often in non- verbal than through verbal.
For example, she saw something bad about an acquaintance; she would rather keep it to herself than to talk to her
personally and point it out on that person. In the next five years, she sees herself successful in the field of showbiz
industry. The client plans to achieve it by trying out in talent searches preferably PBB Teens if there would still be
one. The client is often moody, sometimes she is happy one moment, and then depressed the next. She cannot
clearly say why she feels that way. Things that make her angry are people who are constantly irritating her like
those bugging her questions about what she will be doing for the entire day, who will be with her, what time will
she go home, what is the telephone no. of your classmates, and a lot more. The client feels this way because she
does not want people who act like they are working in the NBI and surveillances her every move as if she is a most
wanted criminal. Having her friends around and going out with them really helps her so much. She cannot control
herself at times and answers back without even thinking about what she is going to say. The client is not satisfied
with her mood because people can be intimated.

L. ROLE - RELATIONSHIP PATTERN

The client lives with her guardians (grandmother, grandfather, uncle, aunt) and 2 younger siblings. Her parents are
working in K.S.A. The client’s family is apart from other families. She stressed that their family is a loud family
because of her grandmother that does not seem to get tired of ranting about things. Obviously, the client does not
get along well with her grandmother because of her self-centered attitude as she said. The client is the eldest in the
three of them. She has the responsibility to check if they have done all their tasks correctly and she is able to fulfill
it. Problems in the client’s family have not reached its height that is why we can live up with that everyday. Her
grandmother usually has the final word about a certain family issue. The client thinks that voicing out opinions
serve as an outlet to enhance your thought processes. She feels powerful and functional when it comes too voicing
out opinions. The client sees a true friend as someone who will always be there for you when the whole world turns
their back at you. She feels this kind of friendship among her high school classmates and high school best buds. Her
friends are a rare find because despite distance and lack of time, they see to it that they still have communication
with one another. The client’s college life goes very well. She feels satisfied that she is studying in FEU.

M. SEXUALITY - REPRODUCTIVE PATTERN

The client first experienced menstruation when she was in grade 6, age 12. Her menstruation cycle is regular with
an interval of 30 days. Her menstruation lasts from 4-5 days. In a day, the client uses 2 pads, one in the morning and
one at night. Sometimes it depends on the heaviness of flow. The client does not experience dysmenorrheal. The
client firmly believes that she is feminine. She would of course like to have the opposite sex as her partner. The
client is not currently engaged in an intimate relationship and likewise she is not involved in premarital sex.

N. COPING - STRESS TOLERANCE PATTERN

The client perceives major exams in subjects like anatomy, healthcare, and physics as a good source of large
amounts of stress. The stress that she experiences is great because of lots of memorization and analysis to be done.
She rarely spends her time alone because she is an outgoing and very friendly person. The client handles stress or
pressure by just facing those stressors and takes it as a challenge. She said that it is effective for her. Her friends are
the people helping her a lot in coping up during stressed times. When faced with big problems, she just does her
best to act upon it and hope for the betterment of the situation. She considers it successful because she will not have
regrets later on that she did not do a certain action to solve the problem.

O. VALUE - BELIEF PATTERN

The client says that a person is healthy if she can fulfill her duties and responsibilities very well despite all odds.
Health is as important as life, more important than any material being on earth for the client. The client considers
health as an important thing because no matter how rich or famous we might be, when it comes to health, we are all
equal because we are all humans, susceptible to different diseases. Religion is important in the client’s life because
it can help an individual to have a certain direction in life. According to her, it gives all of us an assertion that we
are on the right tract in facing these obstacles towards a problem-free state. The client is not sure about social values
that she grew up with. In relation to society, the client perceives herself as a student whose role is, of course, to
study and graduate and therefore to contribute to the man power of society.