Patient Assessment Form

Safety Measures: Perform Hand Hygiene Introduce Yourself Explain Process To Patient

Ensure Privacy
Identification Patient’s Name: ----------------------------------------------- Department: ------------------------------
Age: ------------------------- Gender: ----------------------------Marital status: -------------------------
Education level: -------------------------------------------- Occupation: ----------------------------------
Date of Admission ------------------------------------- Medical No -----------------------------------
Admitted from : OPD ( ) ER ( ) Referred: …………………
Situation Medical diagnosis: ----------------------------------------------------
Chief complains on admission: ----------------------------------------------------------------------------
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Background Past medical history: ----------------------------------------------------------------------------------------
Past surgical history -------------------------------------------date-----------------type-------------------
Allergy: Food ( ) Medication ( ) Other: -------------------------
Family history: DM ( ) HTN ( ) Heart disease( ) liver disease ( ) others:-------------
History of smoking: No. of years: --------------- No. of cigarettes /day: -------------
Medications: -------------------------------------------------------------------------------------------------
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Assessment General Appearance: Grooming (tidy, untidy) - Odor ( accepted , unaccepted)
Communication pattern: (normal speech - impaired speech)
Head
Scalp: {dandruff, boldness, normal}. Integrity (intact, not intact)
Hair: - distribution {alopecia, hair loss, thin, normal } - Texture: {oily, dry } – color:………..
Eyes
Conjunctiva: color {pallor, cyanosis, jaundice, normal }
Sclera: {Clear, Yellow, red}. Discharge: {Watery, purulent, non}
Vision: {Clear, Dam, Blurred, Double Vision}. Use of aids: {eyeglasses, contact lenses, non}
Nose:
Color: {red , Cyanosis, normal}.
Nasal discharge: 1-NO 2-YES {mucoid, purulent, watery, bloody}.
Ears:
Hearing ability: {Impaired hearing, deafness, normal}
Color: {red, cyanosis, normal}.
Ear discharge: 1-NO 2-YES {mucoid, purulent, watery, bloody}.
Mouth: -
Odor: 1-accepted 2-unaccepted {foul smell, halitosis, acetone, ammonia, alcohol}
Lips - color {pink, pallor, cyanosis} moisture-{moist, dry, cracked, fissure at corners}
Gum: Color {pink, pallor, cyanosis, red} Moisture: - {moist, dry, rough, smooth}
Abnormalities {gingivitis, bleeding easily, normal }
Teeth:
Color (White, Yellow, black) Complete (Yes, No)
Use of aids:- {artificial teeth , braces , crown , denture } Abnormalities {decay ,
filling , normal }
Tongue:-
Moisture { Moist , dry} Color:- { pink , Pallor, Cyanosis, Surface Coating}
Texture {slightly rough , smooth, swollen }
 Buccal Mucosa:
Color:- {pink , pallor , cyanosis } Moisture {moist, dry}
Abnormalities {Stomatitis , Thrush , Petechiae }
Neck:
Shape: (long Webbing, deviation) Cervical lymph node: {palpable, not
palpable} Neck joint: {movable, stiffness, contracture}
Extremities:
Any abnormality: (pain ,swelling, gangrene, ulceration, hyperkeratosis, normal)
Tremors: 1- YES (coarse, flapping, one or both hand) 2- NO
Nails:
Shape: - {normal , flattening, clubbing, spoon}
Rigidity: - {rigid, brittle} Color {pink , white, bluish }
Skin:
Integrity: - { intact , not intact } Moisture:- {moist , dry} Color :{pink, yellowish}
Elasticity: {elastic ,tight skin, excessive elasticity}
Body warmth :- ( warm, cold, hot)
Skin abnormality (ecchymosis, rashes, Petechiae, abrasion, itching, poor Wound
healing)
Edema: Site------------------- type (pitting, non pitting)
Pressure ulcer: Site------------------------------------------------degree (1st, 2nd, 3rd, and 4th)
Oxygenation
Cough: {dry , productive, none} ventilation (Room air- oxygen)
Nutrition
Eating patterns------------------------- No. of daily meals:------------- special diet:---- -------------
caffeine intake:----------------- Appetite changes:------------------------ nausea/ vomiting:-----
Elimination
Bowel: Usual time: frequency/day: color: consistency:
Odor:
Assess aids: laxatives, suppositories, enemas Problems:- Diarrhea -constipation, none
Bladder:
Usual frequency / day---------------- Assistive devices: - {urinary catheter , condom }
Problems: - Dribbling, polyuria, dysuria, incontinence, urgency, retention,
burning , none)
Connections: Peripheral cannula – central venous catheter – Urinary Catheter - drain
Site :……………………………………………………………………………………..
Date of last care:………………………………………………………………………..
Self care: Patient’s ability for:
- Feeding: Dependent □ With Assistant □ Independent □
- Bathing: Dependent □ With Assistant □ Independent □
- Toileting: Dependent □ With Assistant □ Independent □
- Dressing: Dependent □ With Assistant □ Independent □

Recommendation Common health problems (in the form of Nursing Diagnosis)

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Student name:
ID:
Date: