Patient Nursing Assessment / Initial Evaluation Form Page 2
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NUTRITIONAL STATUS
_____Ht. _____Wt.
__________________________Diet
ο Oral
ο Enteral
ο Parenteral
_____ Recent Weight Loss
_____Over Weight
_____Under Weight
Fluid intake/day___________________________________________________Meals prepared by_____________________________
ACTIVITIES OF DAILY LIVING (Check appropriate boxes)
APPLIANCE/AIDS/SPECIAL EQUIP
Level of
Without
Uses a
Help of
Device
Dependent
Not
Ambulation aid, other
Has
Needs
Independence
help
Device
Another
& Help
Does not do
Deter
Prosthetic Device
Eating
Tub Stool
Toileting
Hospital Bed
Transfers
Transferring Equip
Ambulation
Toileting Equip
Dressing
Dressing Equip
Bathing/Shower
Colostomy Bag
Shopping
Cane
Housekeeping
Walker
Laundry
Grab Bar
Prepare meals
Commode
Transportation
Oxygen
Handling Money
Wheelchair
Using Telephone
Leg Brace
Other
FAMILY/ SUPPORT SYSTEMS:
ο family (specify)_____________________________________________
ο other (specify)_____________________________________
ο lives alone
Informal caregiver(s) is (are) able to receive instructions and provide care?
ο Yes
ο No
TREATMENTS
Nationwide Medical Waste 1-954-747-8858
SUPPLY NEEDS (check box)
Has
Needs
CLIENT’S COMPREHENSION OF DIAGNOSIS:
EMERGENCY SAFETY INSTRUCIONS GIVEN?
ο YES ο NO
MAJOR NURSING DIAGNOSIS/PROBLEMS REQUIRING ATTENTION:
SHORT TERM GOALS
LONG TERM GOALS:
SIGNATURE__________________________________________________________________DATE_________________________________
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