Name:___________________________ SS#_______________
 

I. IDENTIFYING DATA

A. Client's Initial__________________B. Age__________C. Sex_________D. Ethnicity_____________

E. Occupation (Self)___________________________________________________________________

    (Spouse)_________________________________________________________________________

F. Other sources of income______________________________________________________________

G. Marital status________   H. Number in household___________________   I. Religion______________
 

 
A Informant____________________    B. Level of responsiveness/reliability_____________________

C. Chief complaint (in client's words)_____________________________________________________

D. History of present illness (narrative format of investigation of symptoms_______________________

_________________________________________________________________________________

_________________________________________________________________________________

E. Past medical history

1. Description of general health and chronic health problems immediately prior to illness ________

____________________________________________________________________________

____________________________________________________________________________

2. Previous illnesses_______________________________________________________________

______________________________________________________________________________

3. Previous surgeries_______________________________________________________________

______________________________________________________________________________

F. Allergies__________________________________________________________________________

G. Pattern of regular exercise (home)_____________________________________________________

________________________________________________________________________________

H. Psychosocial history

1. Sleep pattern at home (hrs/time of day, environment, aids to sleep)

___________________________________________________________________________

2. Activities of daily living (self-care or reliance on others)

______________________________________________________________________________

______________________________________________________________________________

3. Habits: tobacco_____alcohol_____drugs_____

4. Housing and living arrangements (house/apt. other)______________________________

______________________________________________________________________________

5. Environmental conditions (home, work) ______________________________________________________________________________

______________________________________________________________________________

6. Family responsibilities and role functions ____________________________________________________________________________

_____________________________________________________________________________

7. Interest or hobbies (use of leisure time) ____________________________________________________________________________

_____________________________________________________________________________

8. Patterns of interaction and communities (close friends)

Participates in groups? Assertive? Shy/withdrawn? Family relationships?

______________________________________________________________________________

______________________________________________________________________________
 

9. Mental Status (affect, judgment, insight, intelligence)

_____________________________________________________________________________

10. Self-concept: 5 = Feel Good 1 = Feels Bad
 

How do you feel about yourself? 5 4 3 2 1

11. Coping mechanisms

a. What are some of the stresses you are feeling in your life?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

b. What do you do to make yourself feel better when you are under stress?

____________________________________________________________________________

____________________________________________________________________________

c. Who gives you support in times of stress?___________________________

________________________________________________________________________
 

12. Spirituality

a. Spiritual attitude?______________________________________________________

____________________________________________________________________________

b. In whom or what do you find a source of strength or meaning?

____________________________________________________________________________

c. Religious practice________________________________________________________

____________________________________________________________________________

13. Sexuality (companionship, intimacy, physical expression)

______________________________________________________________________________

______________________________________________________________________________

a. Degree of satisfaction with usual sexual expression

____________________________________________________________________________

b. Dysfunction of sexuality related to illness/treatment

____________________________________________________________________________

____________________________________________________________________________

Interpret and discuss previously listed psychosocial findings for adaptive or maladaptive patterns

A. Determine developmental level and attach list of appropriate developmental tasks.

B. Gives examples of how client has/has not achieved these tasks.

• If client has not achieved these tasks, at what level is he/she functioning?
• List the factors which may contribute to the developmental level.

IV. EDUCATIONAL ASSESSMENT

• Educational level (last grade attended, level of reading/understanding)

           ______________________________________________________________________________

• Motivations/barriers to learning____________________________________________________

•  Specific learning needs identified (include appropriate time frame)

            ______________________________________________________________________________

• List others to be included in teaching________________________________________________

V. NUTRITIONAL ASSESSMENT (collect data from client, family member, and/or other health caregivers)

A.  Patterns of intake

1. Prescribed diet________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

2. Ability to chew/swallow: Normal_____Impaired_____

Describe:____________________________________________________________________

____________________________________________________________________________
 

3. Sociocultural/religious influences_________________________________________________

____________________________________________________________________________

____________________________________________________________________________

a. Food preferences____________________________________________________________

b. Food dislikes_______________________________________________________________

4. Usual method of food preparation________________________________________________

____________________________________________________________________________

____________________________________________________________________________

B. Describe client's typical 24-hour intake at home.
 

Breakfast                      Lunch                     Supper                 Snacks

C. Analysis of nutritional assessment (summarize your assessment of the client's nutritional status according to the four basic food groups, methods of food preparation, fat, fiber, and vitamin content and for age, analyze whether 24-hour intake meets (RDA).___________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

D. Positive findings in ROS, physical examination and lab data which indicate nutritional deficit _________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

E. Nutritional consultation
 

1.Has nutritional consultation been requested? Yes_________ No__________

2.Has nutritional teaching been done?  Yes_________ No__________

   If yes, by whom?___________________________________________________

3. Who buys and prepares the food?________________________________________________

4. Has this person been included in the teaching?______________________________________

5. Identify nutritional learning needs________________________________________________

___________________________________________________________________________

____________________________________________________________________________

6. What community or institutional referrals are needed?________________________________

____________________________________________________________________________

F. Physical finding

1. Height__________Weight__________

2. Body frame type: Small__________Medium__________Large__________

3. Ideal weight for height/frame________________________________________

4. Variation from ideal (# of lbs. over/under) _____________________________

FOR CLIENT UNDER 18 YEARS, LISTED PERCENT FOR:

Weight/age_______________________ Height/age:____________________

• Related assessments

(list and identify the effect the drug has on nutrition)

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

2. Major illnesses/chronic illness/surgeries/physical alterations/development factors identified

as affecting nutritional intake____________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

VI. Medications (Prescriptions/OTC)
 
 
 
 
 
 
 
 
 
 
 
 
 

VII. Nursing Diagnoses (List all appropriate diagnoses and work up the top priority diagnosis)
 
 
 
 
 
 
 
 
 
 
 
 
 

Revised April, 1997

Revised June, 2000