Shankarappa's Metro Health Kurubatt, Near Mathigit X Road, Ngtroueat® CURRENT MEDICATIONS Kelamangalam Road, Hosur - 635 110. Call: 9159444493, 9003847551 Medication Dose Route Frequency Last dose taken 1 2 3 4 5 Disposition of medications : HiInstructed to Q Other None brought send home Placement __to hospital PAINASSESSMENT (Acute (<6 Wk. Duration) J Chronic (>6 Wk. Duration) ® ® ANALOG SCALE VERY SEVERE EXTREME PAIN PAIN PAIN PAIN PAIN 12.3145 PSYCHOLOGICAL STATUS 1 Anxious O Depressed O Angry O Combative O Sleep disorder O Other NURSING NEEDS ACTION NEEDED 1. Is there a language problem D Yes /Q No 2. Any cultural / religious barriers? CL 3. Is the patient at risk for fails? D Yes /Q No 4, Can patient perform daily acitivites DY 0S /Q.NO siasnnnnnnininninaiee 5. Is the patient incontinent? D Yes /Q No 6. Does patient requires oxygen therapy? DY 0S /Q.NO wisennnnninininninnaien 7. Does the patient have a tracheostomy? OD Yes /Q No 8, Any psychological problem? Des 1D. NO siesennnnniininainnnaie 9. Is the patient in pain? D Yes /Q No 10. Is the patient at risk for pressure ulcers? Yes / No 11. Any special nutrition needs? DY€5 JO) NO wsntsnnnninntnnnneenie 12. Does the patient have any artificial prosthesis? Yes /Q No 13. Any other need D Yes 1. NO sisennnnnnninnninnnneie Form completed by Signature Date Time