Nursing Admission Assessment Template
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5NAME OF HOSPITAL
Nursing Admission Assessment
Date: __________Time: ___________
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Informant:
Patient
Other _______________ Phone #:
_________________________________________________
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Mode of access:
Ambulatory
WC
Stretcher
Other
___________________________________________________
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Transported with
Oxygen
Monitor
IV
Other ___________________________________________________
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From:
Home
ER
Dr. Off.
AFC
ECF
Other __________________
Accompanied by: ______________________
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Valuables:
None
Sent home with _____________________________________________________________
Lock-up
Reason for Admission (Pt’s own words):
_________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Vital Signs
T
O
P
Reg
SaO
R
BP
Ht
Wt
S
Kg
2
R
Irreg
B
A
T
W/C
Allergies
Allergies
Reaction
Allergies
Reaction
Allergies
Reaction
Latex? Y or N
Chronic conditions:
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Lung Problems _____________
Stomach Problems _______________
Thyroid Problems _______________
Neurological Problems________
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Heart Problems ______________
Liver Problems __________________
Vision Problems ______________ __
Kidney Problems ____________
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Arthritis
Diabetes
Chronic infection _________________________ Treatment:
____________________________
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Cancer (where/type) _________________________________________ Treatment:
____________________________
Other Past Medical History or Surgeries: __________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
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Family history –
NSF
Heart disease
Hypertension
Diabetes
Stroke
Seizures
Kidney disease
Liver disease
Medications
Medication
Dose
Frequency
Taken
Brought
Medications
Dose
Frequency
Taken today?
Brought
(include OTC)
today?
with?
(include OTC)
Y or N
with?
Y or N
Y or N
Y or N
Social History
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Lives alone
Lives with ____________________________________________ Stairs at home
Yes
No
Sleep pattern ______________
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Meds sent:
Home with _______________________________
Lock-up
Not applicable
Immunizations current?
Yes ______ No ______
Last Tetanus toxoid? ______________________
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Nicotine Use:
No
Yes – How much? _______ How Long? ________________
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Instructed on Name of Hospital “No Smoking” Policy?
Yes
No Do you live in a smoking environment?
Yes
No
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Alcohol Use:
No
Yes – How much? _____________ How Long? _____________ Last Drink?
______________________________________
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Social Drug Use:
No
Yes – Type? _________________________________ Frequency?
_____________________________________ ___________
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Support Services:
No
Yes – Type
HHC
Hospice
Other
__________________________________________________________________
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Additional Help needed?
No
Yes – Referral made to
____________________________________________________
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