‘Shankarappe's Metro Health Kurubat soankreps NURSING Near Mathigil X Road, MetroHealtn® ADMISSION ASSESSMENT ‘ezine Patient's Name Age sex:MO FO] IPD Ne Date : . Time... Patient arrival from : C1 Home O Casualty OPDO Other Informant: (Patient Other : Whom :... Relationship Contact in case of emergency : Whom Relationship. Ph. No Interpreter needed Yes yes Valuables/Belongings : () None Q]With Patient — Sent Home With Vulnerable Yes (No Restraint Yes (No Bed Sore DYes ONo VITAL SIGNS Temperature .. Pulse. BP . Respiration Pain (0-10)... Height Weight PERSONAL BELONGINGS Dentures (None Upper Lower 0 Partial Hearing Aid Q Right =O Left Eye Aid O Yes Q No Contact Lens Q Yes Q No Jewellery O Yes G No Prosthesis/Implants O Yes No ORIENTATION TO ENVIRONMENT Room O Television O Bathroom 2 Nurse Call Bell Q Visiting Time No Smoking Policy Telephone Facilities 1 Side Rails O Patient Health Handbook O Patient's Rights & Responsibilities Q Unable to orient to the environment due to patient's condition : ALLERGIES AND ADVERSE DRUG REACTIONS Suspected allergies to @ Known Unknown Adverse Drug Reaction Name of medication and description of reaction : Medication / Drugs Q Yes No Blood Transfusion Q Yes No Food Q Yes No Latex Q Yes Q No ORIENTATION TO ENVIRONMENT O Age below 12 O Age below 65 Q Recent history of Fall Q Impaired Judgement CVS 1 CNS Medication O Post-operative sedation O Sensory Deficit O Muscular Weakness Q Others