Adult Patient Admission History
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2
3
4I. Patient Information
Admitted from:
Time Admission:
Chief Complaint/Associated Symptoms:
Ht.
Wt.
lb/kg
Standing Scale
Bed Scale
Stated
Temp
Pulse
Resp
BP
Patient Identification Band on?
Yes
No
PMD
Emergency Contact:
Latex Sensitivity
No Known Allergies
Nickel or Jewelry Allergy
II. Allergies
If yes, Allergy Band on:
Yes
No
Charted Labeled:
Yes
No
Entered into Computer
Yes
No
Food/Drug/Substance
Type of Reaction
See attachment
III. Medications
Medications you are now taking, including: Non-Prescription, Aspirin, Birth Control Pills/Vitamins/Supplements/Herbal Remedies:
Drug/Dosage/Route
Last Dose
Personal Medications
None
Sent Home
Inpatient Pharmacy
Bedside
Unable to obtain pain history due to patient condition.
Pain Assessment:
IV.
Do you have any ongoing pain problems?
Yes *
No, If yes, where
Do you have pain now?
Yes*
No If yes, where
*If yes to either of the above describe your pain:
aching
burning
cramping
crushing
dull
pounding
sharp
shooting
sore
stabbing
tender
tingling
throbbing
other
How often do you have pain (frequency)?
How long does the pain last (duration)?
Continuous
Intermittent
With Movement
How long have you had this pain?
Using one of the following scales, indicate your present level of pain:
now
at worst
at best
What level of pain is acceptable to you?
LEVEL OF PAIN
What causes or increases your pain?
What, if any, treatment(s) do you receive for your pain?
Is the treatment effective?
Yes
No
Are the pain medications effective?
Yes
No
What impact does the pain have on your life and daily functioning?
V.
Social Profile
Religious/Cultural Needs:
Primary Language Spoken:
Interpreter Needed?
No
Yes If Yes, Specify:
Employed/Occupation:
Out of Country Recently?
No
Yes
Where/When?
VI. Psychological Profile
Alcohol use
Yes
No
How much?
Last used:
Recreational drug use:
Yes
No Type & how much?
Last used:
Victim of violence/abuse:
Yes*
No
Physical
Verbal
Emotional
Mental
Are you thinking of taking your own life?
Yes * (Contacting attending MD)
No
History of
Alcohol abuse
Victim of violence abuse
Suicide attempt
Drug abuse
*If yes, referral to Social Work.
Yes
PATIENT IDENTIFICATION
INOVA HEALTH SYSTEM
ADULT PATIENT ADMISSION HISTORY
Name
Date:
Last,
First
DOB __/__/____
Page 1 of 4
Mo/ Day/
Year
CAT # 81789 / R102904
MR24-00
PKGS OF 100
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