MRTRO COLLEGE OF NURSING

FORMAT OF ASSESSMENT FOR ADOLESCENT

Identification Data:
Name…………………………………………………………
Age .................................
Gender………………………….………………
Address ………………………………………………………
Date of Birth ................/………....../……………
Father’s Name……………………………..…………….
Mother’s Name …………………………….……………
No. Of Brother/ sister ….……………………………
Educational status..........................................

Physical Examination:
Anthropometric Measurements:
Anthropometry In the child Normal range
Height (cm)
Weight (kg)
Any significant findings
Vital Signs:
 Temperature :
 Pulse:
 Respiration:
 Blood Pressure:

History of any Congenital Abnormality- Yes/No …………………………….

(If “yes” describe)………………………………………………………………..

Head to Foot Assessment:

Skin:
Scalp:
Hair:
Ears:
Eyes:
Nose:
Teeth & Gum:
Tongue:
Neck:
Chest:
On Inspection
 On Palpation
On Percussion
On Auscultation
Breast & Axilla
Abdomen
On Inspection
On Palpation
On Percussion
On Auscultation
Musculoskeletal
Gait
Joints
Nails
Extremities
Genetalia
Mental Status Examination
Appearance:
Dress: Grooming: Unusual physical characteristics:
Behaviour:
Mannerism: Eye contact: Motor behaviour:
Expressive speech:
Fluency: Pressure: Volume:
Cognition:
Orientation: Abstraction: Intelligence:
Mood/ Affect:
Depression: Agitation: Anxiety: Irritability:
Suicidality/ Homicidality:
Thoughts: Behaviour: Risk to self or others:
Attitude/ Insight/ Strength:
Adaptive capacity: cooperation: Judgement:
Substance abuse/ use:

Growth and Development:-

Gross Motor Development
Fine Motor development
Intellectual development
Psychosocial development – Family Support
Moral development
Spiritual development
Developmental Milestone
Gender identity:
Sexual orientation:
Relationship/ Support system:
Independent:
Moral development:
Health History:
Does the client have a past or present history of the following?
Asthma Diabetes
Attention deficit hyperactivity disorder Orthopaedic injury/ disability
Chronic or recurrent Otitis media Seizure
Congenital or acquired heart disorder Speech, hearing or visual impairment
Developmental/ learning problem Allergies.
Other Somatic or psychiatric diseases specify: .........................................................................

Present Health Status

………………………………………………………………………………………………………
…….................................. .............................................................................................................
Past Health History
………………………………………………………………….…………………………………
………………………………………………………………………………………………………
………………………………………………………..........................................
Menstrual history
Age of Menarche........................year
Cycle....................................
Related factors
Sexual/ Physical/ Emotional abuse:
Sleep Pattern:
Eating pattern:
Hygiene:
Aggressiveness:

Family History:-
Sl. Name of Relationship Age Gender Educatio Occupation Health Remark
No Family to the client n status
. members
Medical History:
Sl. Name of the Dose/ Route/ Period Effectiveness, Response, Side
No: medicine Frequency taken effect.

Immunization:- Yes/No
Sl. Name Of At 1 2 3 4 5 I II III Remark
No. The Birth Dose Dose Dose Dose Dose Booster Booster Booster
Medicine Dose Dose Dose
1 B.C.G.
2 O.P.V.
3 Vita. A
4 D.P.T.
5 M.M.R.
6 Hepatitis
7 T.T.
8 Others

Dietary Pattern (24hrs Recall)

Food Items Cooked Raw Caloric Protein Fat Calcium
Amount Amount (K. Cal) (gm) (mg)
Breakfast
Mid morning
Lunch
Tea
Dinner
Total Intake
Normal requirement
Deficit

Actual Wt of the child

Degree of Malnutrition = ---------------------------------X 100
Expected Wt.

BMI: Weight of child in Kg

Height in m2
Diagnosis
Health Teaching