NURSING ASSESSMENT FORM

PERSONAL AND SOCIAL HISTORY:

CIVIL STATUS: ☐MARRIED ☐SINGLE PREGNANT ( If Female ): ☐YES ☐NO

LMP __________________________
ALLERGY: ☐YES ☐NO
FOOD: _________________________ MEDICINE: ______________________
SMOKING: ☐YES ☐NO ALCOHOL: ☐YES ☐NO
If yes how many stick per day ____________ If yes how frequent? ____________________

MEDICAL HISTORY:

☐ANGINA ☐HEART RHYTHM ☐EASY BRUISING TENDENCY

☐BLOOD CLOTHS IN LEGS DISTURBANCES ☐PROLONGED BLEEDING
☐HEART ATTACK ☐FREQUENT PNEUMONIA ☐RECURRENT INFECTIONS
☐PACEMAKER ( CARDIAC ) ☐DIABETES ☐POOR WOUND HEALING
☐PULMONARY EMBOLISM ☐HEPATITIS ☐JAUNDICE
☐STROKE ☐KELOIDS ☐BRONCHITIS
☐ASTHMA ☐HIGH BLOOD PRESSURE ☐CONGESTIVE HEART FAILURE
☐BLOOD DISORDER
OTHERS:

SURGICAL HISTORY: ( Please specify procedure and the date of the surgery )

Have you had General Anesthesia? ☐YES ☐NO Have you had Local Anesthesia? ☐YES ☐NO
Any Adverse reaction? (Specify) Any Adverse Reaction? (Specify)

CURRENT MEDICINE: (Including herbal medicine, vitamins & minerals, prescribed medicine, maintenance and
over the counter medication with dose and duration )

1. 6.

2. 7.

3. 8.

4. 9.

5. 10.