HEALTH STATUS / VITAL SIGNS Height: (Feet) Height: (Inches) Weight: (Pounds) Waist Circumference: (In) Body Mass Index: (BMI) BMI Calculator Temperature: (Degrees) Temperature Method:  Axillary  Ear  Oral  Rectal  Temporal Pulse: (Beats / Minute) Pulse Method: Pulse Description:   Weak  Irregular  Bounding Respiration (Breaths / Minute) Respiration Description:   Shallow  Wheezing 02 Saturation: (%) Blood Pressure #1: Blood Pressure Position #1:  Lying  Sitting  Standing Blood Pressure #2: Blood Pressure Position #2:  Lying  Sitting  Standing Blood Pressure #3: Blood Pressure Position #3:  Lying  Sitting  Standing Vital Signs Comments: (Indicate where on body blood pressure was taken each time). Appearance Hair Color:  Bald  Brown /  Shaved  Black  Gray  Other (specify)  Blonde  Red / Hair Comments: Eye Color:  Blue  Green  Brown  Hazel  Gray  Other Eye Comments: General Appearance:  Adequate oral care  Appears older than stated  Appears stated age  Appears younger than stated age  Clean  Clothing inappropriate to season  Disheveled  Excessive / Inappropriate make-up  Malodorous  Neat  Poor grooming  Poor oral care  Other (specify) 2
HEALTH STATUS / VITAL SIGNS (continued) Caffeine Use?  No  Yes  Unknown Caffeine Use Comments: (Include duration and frequency per client response). Has Gambling Ever Interfered With the Quality of Your Life?  No  Yes  Unknown Gambling Comments: (Include duration and frequency per client response. Include financial / personal losses as a result of gambling habit). Pain Assessment Do You Have Any Pain or Discomfort? (Complete manual / paper pain assessment)  No  Yes  Unknown Pain Comments: (Include pain location, duration, frequency and how it may interfere with quality of life). Sleep Pattern Current Sleep Pattern:  Difficulty falling asleep   Sleep apnea  None  Enuresis  Nightmares  Sleep walk  Other (specify)  Insomnia  Requires sleeping aid (specify)  Walking during night Sleep Aid Note: (List any medications, devices, etc. that are required as an aid in sleeping). Sleep Comments: (How long since slept)? (Include client’s responses and information obtained from previous hospitalization records). Nutrition Nutrition Issues:  Appetite Loss (50%<intake 3 days)  Difficulty chewing / Swallowing / Choking  High Cholesterol / Triglycerides  History of bulimia  HIV  Kidney disease  Non-insulin dependant diabetes  Tube feedings  Use of MAO inhibitor  Other (specify)  Decubitus  Food Allergies  History of anorexia  History of polydipsia  Insulin dependent diabetes  Morbid obesity  Pregnancy  Use of anticoagulant  Wasting appearance (<20% IBW) 10# loss / Gain Nutrition Comments: (Indicate duration of issues noted with current / past effective / non-effective treatments if known). Current Diet: Nutrition Special Needs / Supplements: (Indicate frequency of supplements and any specific food / drink items preferred). 4
SYSTEMS (continued) Adaptive Equipment Note: Musculoskeletal Comments: (Include duration frequency and severity of any signs / symptoms. Include current / past treatment and how issues may have affected client’s quality of life). Gastrointestinal Date of Last Bowel Movement: (If yes listen to client’s bowel sounds and single select from bowel sounds list). Abdominal Distention:  No  Yes Bowel Sounds:  Absent  Faint  Hyperactive  Present Gastrointestinal:  Constipation  Flatus  Hemorrhoids  Ostomy  Vomiting  Diarrhea  GERD  Hiatal hernia  Rectal bleeding  No known difficulty  Encopresis  Heartburn  Nausea   Other Gastrointestinal Comments: (Include location of active or absent bowel sounds (per quadrant). Include frequency, duration and severity of issues. Include how issues may have affected client’s quality of life). Endocrine Endocrine:  Hyperthyroidism  Hypothyroidism  No known difficulty  Other (specify) Endocrine Comments: (Include duration and current /past treatment if known). Does Client Have Diabetes?  No  Yes  Unknown Diabetes Treatment:  Byetta  Insulin Pump  Diet  Oral Medication  Insulin  Other (specify) Diabetes Comments: (Include duration, severity and factors known to affect blood sugar. What is client’s usual blood sugar range). 7
SYSTEMS (continued) Ability to Understand Verbal Instructions?  No  Yes  Unknown Verbal Communications Comments: (Include specific known issues and client’s lack of response during the assessment if pertinent). Dental Issues:  Bleeding  Edema  Pain  Other (specify)  Braces  Edentulous  Partial plate  Dental caries  Loose teeth  Retainer  Dentures  Missing teeth  No known difficulties Last Dental Exam Date (month, day, year): (If Dental Comments: (Include duration, frequency and severity of dental issues). Integumentary Integumentary: (Complete Wound Assessment for all choices, including No Known Difficulty)  Clammy  Dry  Warm  Cold  Flushed  No known difficulty  Cyanotic  Jaundice  Other (specify)  Diaphoretic  Pale Integumentary Comments: (Include duration, frequency and severity of issues. Include current / past treatments if known). Skin Condition:  Birthmarks  Lesions  Tattoos  Bruises  Piercings  No known difficulty  Burns  Rash  Other (specify)  Decubitus  Scars Skin Condition Comments: (Include location and description) Podiatry Concerns:  Athlete’s foot  Corns  No known difficulty  Blisters  Ingrown toenails  Other (specify)  Bunions  Spurs  Calluses  Warts Podiatry Comments: (Include location and description) (Include duration and severity. Include current / past treatments if known). 9
PRESENTING PROBLEMS / BEHAVIORS (continued) Current Affect:  Appropriate  Blunted  Flat  Inappropriate  Current Affect Comments: (Elaborate on current affect). What Upsets Client / Behavioral Triggers:  Authority conflicts  Boredom  Delay of request  Invasion of privacy  Other people talking about me  Provoked / Teased  Being ignored  Certain time of year  Delusions  Loss of property  Pain / Discomfort  Task demand  Being touched  Darkness  Hearing voices  Noise  Personal space /  Other (specify) Behavioral Triggers Comments: (Include client responses. Include special examples if known). Behaviors When Triggered:  Bite  Destroy property  Hit people  Kicks people  Self-Injurious behavior  Throws things  Cry  Fight  Hit things  Kicks things  Spits  Yells  Curse  Get away  Isolates self  Pacing  Throws  Other (specify) Triggered Behavior Comments: (Include specific examples if known). What Have You Tried That Helps You Calm Down or Cope?  Drugs / Alcohol  Meditation / Deep breathing  Smoke  Other (specify)  Journaling  Pray  Talk about it  Listen to music  Self-Injurious  Walk / Exercise Coping Comments: (Include effectiveness of coping skills). 12
TRAUMA / RISK (continued) Trauma Have You Ever Experienced Physical, Emotional, or Sexual Abuse or Neglect?  No  Yes  Unknown Abuse Comments: (Include current and past episodes). Physically, Emotionally, Sexually Abused Another Person?  No  Yes  Denies  Unknown Abuse Perpetrator Comments: Ever Tried to Hurt Yourself in the past? (If yes, complete self harm comments).  No  Yes  Denies  Unknown Thoughts of Doing Harm to Yourself Now? (If yes, complete self harm comments).  No  Yes  Denies  Unknown Self-Harm Comments: (Include client statements) (Complete Suicide Assessment) ALERTS / PLAN OF CARE Physician Alert:  No  Yes Physician Alert Type:  Audiologist  Dental  Dietary  Internal medicine  Ophthalmologist / Optometrist  Speech therapy  Burn care  Dermatology  Educational  Neurology  Physical therapy  Wound care  Cardiology  Diabetic  Infection control  Occupational therapy   Other (specify) Physician Alert Comments: (Specify other and elaborate on physician alerts). 14