Patient Nursing Assessment / Initial Evaluation Form printable pdf download

INITIAL EVALUATION AND NURSING ASSESSMENT

Patient_________________________________________________Age___________Ethnicity____________________________________

Religion____________________________Marital Status______________________Occupation___________________________________

Informant______________________________________________________Reliability__________________________________________

DIAGNOSES: (list all diagnoses, surgical procedures & complications

HISTORY OF PRESENT ILLNESS

relating to present condition and dates.)

ENVIRONMENTAL EXPOSURE TO POLLUTANTS/TOXIC

ALLERGIES

AGENTS & DATES

CHILDHOOD DISEASE/

MILITARY HX, TRAVEL & DATES

RISK FACTORS(circle all that apply)

IMMUNIZATIONS

SMOKING

DIETARY

OBESITY

DRUGS

LACK OF EXERCISE

ALCOHOL

SEXUAL BEHAVIOR

HISTORY OF PERTINENT PAST ILLNESS, HOSPITALIZATIONS,

FAMILY HISTORY – GRANDPARENTS, PARENTS, SIBLINGS

SURGERY, DATES

REVIEW OF SYSTEMS

COMMENTS

INTEGUMENTARY

Rash, pruritus, lesions, dandruff, changes in skin, hair or nails,

ulcers, wounds, incisions (describe on wound sheet)

NEUROLOGICAL

Headaches, injuries, fainting, seizures, tremors, numbness, tingling,

dizziness, paralysis, changes in memory, touch, taste, smell,

hearing, vision, pain and/or sx of infection in eyes or ears, tinnitus,

use of glasses, contact lenses, hearing aid

RESPIRATORY

Cough and characteristics, sputum, dyspnea, wheezing, hemoptysis,

congestion or discharge from nose, pain in throat, nose or chest,

epitaxis, throat infections, asthma, bronchitis, pneumonia,

emphysema, upper respiratory infections

CARDIOVASCULAR

Chest pain, edema, dyspnea, palpitations, hypertension, heart

condition, phlebitis, trouble with circulation to the extremities

GASTROINTESTINAL

Abdominal pain, nausea, vomiting, diarrhea, constipation,

hemorrhoids, indigestion, swallowing, appetite, excessive flatus or

belching, changes in stool color, consistency or frequency, mouth,

teeth or chewing problems, partial or complete dentures, hepatitis,

diverticulitis, gallstones, peptic ulcer, colitis, ostomy.

RENAL

Difficulty in urination, dysuria, dribbling, incontinence, urgency,

frequency, infections, stones

MUSCULOSKELETAL

Pain or stiffness in joints, redness, swelling, limited ROM, fatigue,

weakness, pain in muscles, arthritis, fractures, deformity, tumor,

infection, ambulation, use of assistive devices

ENDOCRINE

Diabetes, thyroid condition, increase in thirst, appetite, urination,

heat or cold intolerance, breath odor, changes in weight/stamina,

fat distribution

HEMATOPOIETIC

Anemias, bruising, previous transfusions, skin hemorrhages,

petechiae, blood dyscrasias, leukemia, immune disorders

REPRODUCTIVE

Lesions on or drainage from penis or vulva, rashes or irritations on

penis or vulva, vaginal infections, venereal disease, infertility, birth

control, sexual difficulties, age at menarche and menopause,

number of pregnancies, abortions, live births, complications during

pregnancies, LMP, lumps or pain in genitalia (M or F), date of last

PAP and Mammogram

PSYCHIATRIC

Depression, nervousness, mood swings, insomnia, self-concept,

effect of stress, thoughts of suicide, substance abuse, ETOH abuse

Patient Nursing Assessment / Initial Evaluation Form

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