KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES NURSING ASSESSMENT FORM

Name: Sex Pulse ALLERGIES Weight Resp DOB: KCMHSAS ID #: Height B/P: Date: Case Mgr

Recent Lab, X-Ray, Other Test Data: Psychiatrist: Last Seen: Physician 1: Last Seen: Physician 2: Last Seen: Physician 3: Last Seen: Physician 4: Last Seen: Optometrist: Last Seen: Dentist: Last Seen: Current Medications Dose/Frequency Prescribed by

Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Purpose/Effectiveness per Client

Date of Last Tardive Dyskinesia Screen:

(Complete and attach AIMS if appropriate) SUBSTANCE ABUSE HISTORY

Caffeine

Yes

No

Cigarettes (current) packs per day Yes Yes No No

Years smoked

Alcohol (ever used) Drugs & Narcotics (ever used) Type and frequency

By Prescription (sedatives, Minor Tranquilizers, opiates, stimulants, hallucinogens, inhalants, cannabis)

Additional comments pertaining to substance use: Include legal /vocational problems, impact on life/social/family, previous attempts to control: History of Physical Illness (Patient’s response to “What major physical or medical problems, including surgeries have you had in your life?”) (Patient’s response to “What major medical problems, like heart trouble, strokes, or cancer, run in your family?”)

Family History General Appearance Health Affected ADL’s:

(Patient’s response to “Do any your medical problems make it difficult for you to perform independent ADL’s?”)

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KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES NURSING ASSESSMENT FORM
Name: DOB: KCMHSAS ID #: Date:

Identification of Health and Safety Issues REVIEW OF SYSTEMS NEUROLOGICAL YES NO HISTORICAL

CONDITIONS/SYMPTOMS Frequent/Severe Headaches Seizures Dizziness Impaired Balance/Coordination Numbness/Tingling/Paresthesia Paralysis CVA (Stroke) Tremor Head Injury Loss of Consciousness Comments: CONDITIONS/SYMPTOMS Last Eye Examination Impaired Vision: Comments: Correction: Cataracts Glaucoma Blurred Vision Last Hearing Test Impaired Hearing: Comments: Ringing in Ears Earache Discharge from Ear Canal Impaired Sense of Smell Frequent Nose Bleeds Frequent Colds/Sinus Infections Needs Dental Work Mouth/Gum Sores Toothaches Dentures Comments: Breath Odor Describe: Difficult/Painful Chewing/Swallowing Frequent Sore Throats Hoarse Voice/Difficult Speaking Thyroid Enlargement Comments: CONDITIONS/SYMPTOMS Frequent Nausea Frequent Vomiting Indigestion/Heartburn Ulcers Diarrhea Constipation Odd Colored Stool

UNK

DATE

EENT YES NO

HISTORICAL

UNK

DATE

GASTROINTESTINAL YES NO HISTORICAL

UNK

DATE

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KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES NURSING ASSESSMENT FORM
Name: Use of Laxatives Hemorrhoids Diverticulitis Comments: DOB: KCMHSAS ID #: Date:

CONDITIONS/SYMPTOMS Shortness of Breath Wheezing/Congestion/Asthma Productive Cough Fatigue/Restricted ADL COPD Tuberculosis Comments: CONDITIONS/SYMPTOMS Chest Pain Edema HI/LO BP: Medications? Tracy/Brady – cardia Irregular Pulse Numb/Cold Hands/Feet (check digital pulses) Congestive Heart Failure Heart Attack ADL Limitations Comments: CONDITIONS/SYMPTOMS Anemia Sickle Cell Hemophilia (easy bruising/bleeding) Comments: CONDITIONS/SYMPTOMS Frequent Urination Painful/Difficult Urination Nocturia Incontinence Use of Diuretics Cloudy/Bloody Urine Flank Pain Kidney Stones Males Testicular Pain Testicular Self Exam (freq.) Prostrate Problems Females Age of Menarche LMP (date) Regular Periods Menopause (date) Pregnant (EDC) (date) # of Pregnancies # of Live Births # of Miscarriages # of Abortions

RESPIRATORY YES NO

HISTORICAL

UNK

DATE

CARDIOVASCULAR YES NO HISTORICAL

UNK

DATE

HEMATOPOIETIC YES NO HISTORICAL

UNK

DATE

GENITOURINARY YES NO HISTORICAL

UNK

DATE

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KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES NURSING ASSESSMENT FORM
Name: DOB: KCMHSAS ID #: Date: Breast Lumps Breast Self Exam (freq.) Last OB/GYN Exam (date) Vaginal/Penile Discharge Itching in Genital Area Sexually Active If “yes”, Please see attached “Communicable Disease Risk Assessment” Comments: MUSCULOSKELTAL CONDITIONS/SYMPTOMS YES NO HISTORICAL Pain/Stiffness Weakness Impaired ROM Deformities Prosthesis/Orthopedic Appliance Fractures Comments: CONDITIONS/SYMPTOMS Diabetic Hypoglycemia Thyroid Dysfunction Comments: CONDITIONS/SYMPTOMS Flushed/Jaundiced Skin Diaphoresis Poor Skin Turgor Comments: CONDITIONS/SYMPTOMS Average # hrs/night Difficulty Falling Asleep # Times Awake/night Naps during Day Comments: TYPE DPT TOPV HIB MMR TD TDS Comments: CONDITIONS/SYMPTOMS Usual # of Meals/daily Recent Weight Change (>10 lbs.) Recent change in appetite Content with Current Weight Special Diet Needed NUTRITIONAL PATTERNS YES NO HISTORICAL UNK DATE INTEGUMENTARY YES NO HISTORICAL UNK DATE ENDOCRINE YES NO HISTORICAL

UNK

DATE

UNK

DATE

SLEEP PATTERNS YES NO HISTORICAL

UNK

DATE

IMMUNIZATIONS LAST RECEIVED UNK

CURRENT YES

NO

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KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES NURSING ASSESSMENT FORM
Name: DOB: Knowledge of 4 Basic Food Groups Dietary Deficits Appropriate Fluid Intake Food Use as a Coping Mechanism Eating Disorder Comments: KCMHSAS ID #: Date:

SUMMARY/CLINICAL IMPRESSIONS: SUMMARY OF CONSUMER HEALTH GOALS: Overall Health seen as: Strengths as related to Health: Goals as related to Health: (Treatment Recommendations are documented on the Person-Centered Annual Plan [Supported Needs page])

Date: Prepared by (Signature) Name/Credentials

Agency:

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KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES NURSING ASSESSMENT FORM
Name: DOB: KCMHSAS ID #: Date:

COMMUNICABLE DISEASE RISK ASSESSMENT Please answer the following questions to determine if you may need further health screening. The following questions are related to HIV (the virus that causes AIDS), Hepatitis, and Sexually Transmitted Diseases (STD’s): Have you engaged in unprotected sexual behaviors (oral, anal, or genital) with a partner whose health status is unknown to you: Yes No

Have you engaged in sexual behavior with individuals who have been identified as having any of the following? HIV Hepatitis STD’s Yes Yes Yes No No No

Have you shared needles or injecting “works” with other individuals? Yes No

Have you experienced other forms of blood-to-blood or body fluid contact (i.e. blood transfusions, hemophilia treatments, and employment in the medical field), and have concerns regarding your HIV status: Yes No

Please answer the following questions to determine if you may need health screening for TB: Have you recently lived in a treatment facility, homeless shelter, drug house, jail, mental hospital, or in close quarters with persons of unknown health status: Yes Have you recently had close contact with someone diagnosed as having TB? Yes No No

Have you had a chronic cough for more than three weeks and any of the following symptoms? Weight Loss Fever for 3 days or longer Night sweats Coughing up Blood Yes Yes Yes Yes No No No No

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KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES NURSING ASSESSMENT FORM
Name: DOB: KCMHSAS ID #: Date: I understand that I may be risk of contracting HIV, Hepatitis, STD’s, or TB if I answered “Yes” to any of the questions above. I have been informed how HIV, Hepatitis, STD’s, or TB are transmitted; and ways to reduce the risk for contracting these communicable diseases.

Consumer Signature

Date

Completed by: (Signature/Credentials)

Date

55985775.doc Effective Date: 01/16/07 Authorizer: Deputy Director of Access and Emergency Services Application: KCMHSAS Staff and Contract Providers (MH) Supercedes: 07/01 Page 7 of 7

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