1 Assessment Data Form MS-1

Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬

Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
[Type here] ‫كلية التمريض‬
College of Nursing
Medical Surgical Department ‫قسم الباطنة و الجراحة‬
NURSING ASSESSMENT FORM – MS 1
Student Name_____________________________ Year Level & Group:__________

Affiliating Hospital: _______________________________ Date:_____________
I. Demographic Data
Patient Name: _____________________________ Medical Record No.:__________

Nationality:________________________ Gender:______________ Age: _________
Occupation: _______________________________ Marital Status: ______________
Attending Physician: ________________________ Room & Bed No.: ____________
Date of Admission: _________________________Time of Admission: ___________
Admission Diagnosis: __________________________________________________
II. Health History (Subjective Data)
Chief Complaints:
____________________________________________________________________
History of Present Illness:

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Past History: (includes previous illness, hospitalizations, surgeries & other

management)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Past Medications & Allergies:

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
College of Nursing
Family History:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Lifestyle Pattern:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
III. Physical Assessment (Objective Data)
General Survey/Appearance:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Height: ________ Weight: ____________
Vital Signs:
Temperature: _________ Pulse Rate: _______ Respiratory Rate:_______

SaO2:______ BP: _____________ Mean Arterial Pressure (MAP) ________
Pain Scale ________ (0 -10)
Review of Systems (Head to Toe Assessment)
Body Part Assessment Findings Analysis

Examined Technique Used
College of Nursing
Continuation….
College of Nursing
IV. Laboratory Investigations & Diagnostic Procedures
A. Laboratory Investigations
Laboratory Test Normal Values Results Analysis

College of Nursing
B. Diagnostic Procedures
Diagnostic Studies & Procedure Results/Findings
ECG
X-ray for: ___________________

____________________________
CT Scan for: _________________

____________________________
Ultrasound for: _______________

____________________________
MRI for: ____________________

____________________________
Other Special Procedures

College of Nursing
Fluid Intake and Output

Intake Output
Time Amount
Parenteral Oral Amount (ml) Urine Others
(ml)
8 am
2 pm
Shift Total Intake= Shift Total Output=

1 Assessment Data Form MS-1

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1 Assessment Data Form MS-1

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Taibah University ‫جامعة طيبة‬

Al-Madinah Al-Munawara ‫المدينة المنورة‬

NURSING ASSESSMENT FORM – MS 1

Student Name_____________________________ Year Level & Group:__________

Patient Name: _____________________________ Medical Record No.:__________

II. Health History (Subjective Data)

History of Present Illness:

Past History: (includes previous illness, hospitalizations, surgeries & other

Past Medications & Allergies:

III. Physical Assessment (Objective Data)

Height: ________ Weight: ____________

Temperature: _________ Pulse Rate: _______ Respiratory Rate:_______

Pain Scale ________ (0 -10)

Review of Systems (Head to Toe Assessment)

Body Part Assessment Findings Analysis

IV. Laboratory Investigations & Diagnostic Procedures

Laboratory Test Normal Values Results Analysis

Diagnostic Studies & Procedure Results/Findings

X-ray for: ___________________

CT Scan for: _________________

Ultrasound for: _______________

MRI for: ____________________

Other Special Procedures

Fluid Intake and Output

Shift Total Intake= Shift Total Output=

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Student Name___________________ Year Level & Group:

Patient Name: ___________________ Medical Record No.:

Height: Weight: ____

Temperature: _____ Pulse Rate: _ Respiratory Rate:_____