Initial Assessment Form

Patient’s full name; ______________________ MR number: _________________

Date of Admission ____________ Date of Birth ____________ Age (yrs) _______

General History

Gender: ☐ M ☐ F ☐ Other Marital Status: ☐ Single ☐ Married ☐ Other

No. of Children: _________ Job and Occupation: ☐ Armed forces ☐
Farmer/Fisherman ☐ Non-qualified worker ☐ Office worker ☐Retired
☐Unemployed/non active ☐Student
Educational level: ☐Can write ☐Can read ☐ Class: ____________________
Level of Consciousness: ☐ unconscious ☐ confused ☐lethargic ☐ Stuporous
☐ comatose
GCS Level: Eye opening ___/4 Verbal response ___/5 Motor response ____/6

History of trauma/illness:
Date of occurrence _________
Circumstances/etiology:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Associated diseases: ________________________________________________

Medical History/Treatment:
Hospital/health facility ___________________ Care _______________________
Evolution since the beginning: ☐ Improved ☐worsened

Any comments:____________________________________________________
_________________________________________________________________

Psychological Assessment:
Motivation/Emotional Status: ☐Good ☐ Bad ☐ Can’t be determined
Attitude/compliance: ☐ Good ☐ Bad ☐ Can’t be determined
Cognitive Status and others (Mainly for Neurological Conditions)
Concentration/Memory: ☐ Good ☐ Bad ☐ Can’t be determined
Communication (understanding, speaking): ☐ Good ☐ Bad ☐ Can’t be
determined ☐ language barrier
Bowel and Bladder control: ☐ Good ☐ Bad ☐ Can’t be determined
Swallowing: ☐ Good ☐ Bad ☐ Can’t be determined
Breathing (ability to cough): ☐ Good ☐ Bad ☐ Can’t be determined
Vision: ☐ Good ☐ Bad ☐ Can’t be determined
Hearing: ☐ Good ☐ Bad ☐ Can’t be determined

Any Comments: ____________________________________________________

_________________________________________________________________
Living Condition
House: ☐ Good ☐ Bad
Environment: ☐ Rural ☐ Urban ☐ Mountain ☐ Flooded fields ☐ Others (please
specify: __________________________________________________________)
Family: ☐ Present ☐Absent ☒ Others (please specify: ____________________)
Friends: ☐ Present Absent ☐ Others (please specify:
______________________)
Cultural environment: ☐ Supportive ☐ Limitative

Medical and Social Support

Accessibility to Medical Services: ☐ Yes ☐ No
Accessibility to Social Services: ☐ Yes ☐ No
Security Situation: ☐ Good ☐ Bad
Any Comments; ____________________________________________________
_________________________________________________________________

Current Medical History

Reason for admission: _______________________________________________

Current medications: ________________________________________________
_________________________________________________________________
_________________________________________________________________
Comorbid: ☐ Diabetes ☐ hypertension ☐ Heart failure ☐ TB ☐ Asthma ☐
Cancer ☐ Others (Specify ___________________________________________)
Height (cm) ______ Weight (Kg) _________ BMI (kg/m 2) ___________________
Nutritional status: ☐ Normal ☐ Compromised
Activity status: ☐ Up and about ☐ Limited ☐ Up to washroom ☐ Immobility
Level of Assistance required: ☐ Independent ☐ toileting assistance ☐ feeding
assistance ☐ incontinence ☐ breathing assistance ☐ dependent

Addiction to drugs: ☐ Smoking ☐ Beetle nuts ☐ Cocaine ☐ None ☐ Others,

(Specify _________________________________________________________)

Pain score: _____ (out of 10. 1=least 10= most)

If pain score greater than 3 perform the following assessment)
Pain characteristic: ________ Onset _______ Location: __________ Duration:
__________ Exacerbates with: __________ Radiates to: _________ Referred
to:_________

Wound: ☐ Present ☐ Absent

If wound is present, perform the following assessment
Wound type: ☐ Open ☐ Closed
Discharge present: ☐ Yes ☐ No
If discharge is present, then perform the following assessment
Discharge color: _______ Amount: ________ Odor: _______ Consistency: _____

Pressure Ulcers: ☐ Present ☐ Absent

If present, perform the following assessment.
Number of ulcers observed: ____________ Location: ______________________
Stage of the pressure ulcer: ____________ Dressing applied: ☐ Yes ☐ No
Invasive Lines : ☐ Present ☐ Absent
If present, perform the following assessment.
Type: ☐ Peripheral line ☐ Central line ☐ Other (Specify ___________________)
Date of insertion: _____________ Dressing intact: ☐ Yes ☐ No
Redressing date: _____________

Drains: ☐ Present ☐ Absent

If present, perform the following assessment.
Type of drains: ________________________ Location: _____________________
Insertion date: ____________ Dressing status: ☐ Intact ☐ Oozing
Redressed on (date); _____________

Any Comments: ____________________________________________________

_________________________________________________________________

Allergies: ☐ Yes ☐ No If yes, specify; __________________________________

Risk of fall: ☐ Yes ☐ No

If yes, safety measures taken: ☐ ID band ☐ Bed locked ☐ Call bell provided ☐
Side rails up ☐ fall band provided ☐ Others (Specify_______________________)

Assistive devices used: ☐ Crutches ☐ Cane ☐ Wheel chair ☐ walking frame

Other, (Specify ____________________________________________________)

Current treatment plan: ______________________________________________

_________________________________________________________________
_________________________________________________________________

Past Medical History

Any weight loss in the last 6 months: ☐ Yes ☐ No If Yes, specify: _____________
Past illnesses: _____________________________________________________
Past medications: __________________________________________________
Past surgeries: _____________________________________________________
Past medical or alternative therapies: ___________________________________

Any Comments: ____________________________________________________

_________________________________________________________________
_________________________________________________________________

Family History:
Family history of any illnesses: ☐ Yes ☐ No
If yes, please check the box(es) mentioned below.
☐ Diabetes ☐ Hypertension ☐ Glaucoma ☐ Asthma ☐ Arthritis ☐ Heart failure
☐ TB ☐ Heart diseases ☐ Cancer ☐ Gastrointestinal ☐ Others, Specify
_________________________________________________________________

Does any family member smoke? ☐ Yes ☐ No ☐ How much ________________

Does any family member use alcohol? ☐ Yes ☐ No ☐ How much ____________
Does any family member use other substance(s)? ☐ Yes ☐No Specify ________

Interventions and Teaching

_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________

Need for Comprehensive Assessment

☐ Nursing ☐ Social work ☐ Spiritual care ☐ Physician ☐ Bereavement ☐
Dietician ☐ Physical therapy ☐ Neuropsychological ☐ Occupational therapy ☐
Speech therapy ☐ Other Specify _______________________________________

Patient /Caregiver refuses the following services and assessments: ☐ Yes ☐ No

RN signature _______________________ Date: ___________________________