NURSING ASSESSMENT TOOL FOR CLINICAL EXAMINATION (NURS 4011)

STUDENT’S NAME: __________________________________________________________

IDENTIFICATION NUMBER: _______________________________________________
CLIENT’S DATABASE

DEMOGRAPHIC DATA
Name of Patient (Use Initials):________Age: ___________ DOB: __________________
Gender: ______________Ethnicity:__________________Admission Date: ________________
Time: _______________ Number of days/months since admission _______________________
Religion: ________________Current Living Situation (environmental data, structure etc.)
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HEALTH HISTORY
Reason for this (current) visit (primary concern/chief complaint): _________________________
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History of present illness (what were the antecedents): __________________________________
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Cultural/Health concerns (relating to healthcare decisions, religious concerns, pain, childbirth,

family involvement, communication and so on):
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Previous illnesses, hospitalizations, and surgeries (indicate date/year) ______________________
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Client/Family medical history – (for example, hypertension, diabetes, cancer, alcoholism) _____
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Immunizations/exposure to communicable diseases: ___________________________________
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Allergies: _____________________________________________________________________
Current medications (note/compliance: ______________________________________________
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CLIENT DATABASE NCJ 2015, REVISED 2019

Developmental level: ____________________________________________________________
Developmental milestone: ________________________________________________________
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Obstetric history: _______________________________________________________________
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Psychosocial history: ____________________________________________________________
Complementary/alternative therapy use: _____________________________________________
Activities of daily living (Client’s ability to care for self): _______________________________
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Diet/Nutritional history: __________________________________________________________
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Source of information: _______________________Reliability Scale (1–4 with 4 = very reliable): ____
Laboratory/Diagnostic findings: ___________________________________________________
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Ethical and Legal considerations: __________________________________________________
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Health Promotion teaching: _______________________________________________________
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Current Medical Diagnosis/s: (from other health care personnel): _________________________
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Findings on Admission: _________________________________________________________
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Current Medical Management (including medication): _________________________________
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CLIENT DATABASE NCJ 2015, REVISED 2019

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PHYSICAL ASSESSMENT
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CLIENT DATABASE NCJ 2015, REVISED 2019

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CLIENT DATABASE NCJ 2015, REVISED 2019

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CLIENT DATABASE NCJ 2015, REVISED 2019

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Internal Examiners’ Comments:

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Name: ____________________________ Signature: ________________Date: _____________

External Examiners’ Comments: __________________________________________________

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Name: ____________________________ Signature: ________________Date: _____________

CLIENT DATABASE NCJ 2015, REVISED 2019

CLIENT DATABASE NCJ 2015, REVISED 2019