I.

INTRODUCTION
II. DESCRIPTION OF CLIENT’S DIAGNOSES AND ASSESSMENT HISTORY
a) Client’s personal and demographic data and lifestyle factors:
Age:
Sex:
Birthday:
Address:
Role:
Religion:
Weight:
Height:
b) Client’s chief complaint:

c) History of the present illness:

d) Past Medical History:

e) Review of Systems:
 Constitutional symptoms:
Blood pressure:
Respiratory rate:
Pulse rate:
Temperature:
f) Gordon’s 11 Functional Health Patterns
g) Physical Assessment and other Vital Assessment
I. General Survey and Vital Signs
Date:
Time:

VITAL SIGNS MEASUREMENTS

Blood Pressure: Age:
Temperature: Weight:
Pulse Rate: Height:
Respiratory Rate: BMI:
Oxygen Saturation:

GCS
Eye-opening =
Verbal Response =
Best Motor Response =