RNSG 2121 HEALTH ASSESSMENT and PHYSICAL EXAM PATIENT BIOGRAPHICAL DATA (Each Area must be Addressed, leave no blank spaces) Rm #: _____Initials: ____ Gender: _____ Birthdate: __________ Age: _____ Marital Status: __________ Race/Ethnicity: __________________ Religion: _________________Occupation: ___________________ Contact Person: ______________________________ Source of Interview Data: _____________________ Reliability of Source: ____________________________________________________________________ Language: ____________________________ Education Level: __________________________________ Barriers to Learning: ____________________________________________________________________ Growth and Development Erickson’s Stage of: _____________________________________________________________________ Positive Characteristics: ______________________________________________________________________________________ ______________________________________________________________________________________ Negative Characteristics: ______________________________________________________________________________________ ______________________________________________________________________________________ Your Patient is in Phase: _________________________________________________________________ PRESENT HEALTH/ ILLNESS Reason for Seeking Care: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ History of Current Illness: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Health Beliefs and Practices (Cultural Aspects): ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Required Therapies: ______________________________________________________________________________________ ______________________________________________________________________________________ Pain Assessment: P_______________________________________________________________________________ Q_______________________________________________________________________________ R_______________________________________________________________________________ S_______________________________________________________________________________ T_______________________________________________________________________________ Give a brief Synopsis of your patient’s Medical Diagnosis (use your textbook and give reference): ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ PAST HISTORY Childhood Illnesses: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Immunizations: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Hospitalizations: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Surgery (ies): ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Medical Illnesses: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Allergies: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Injury/Accidents: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Emotional/Psychiatric Problems: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Use of tobacco: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Past Use of Alcohol: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Diet/ Nutrition: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Functional Ability: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Health Promotion: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ All Preventive Healthcare Screenings for this Patient: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Home Environment/Social Needs: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Medical assistive devices and Self-Care Ability: (Walker, Cane, Splint/Brace, Crutches, Bedside Commode, W/C, Lap Buddies, Gait Belts, Etc.) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Functional Ability: (Ability to Perform Skills for Independent Living, Assistive Devices, ADL’s, Cooking, Housekeeping, Shopping) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Self-Care Ability: 0 = Independent 1= Assistive Device 2= Assistance from others 3= Dependent Eating/drinking Dressing/grooming Toileting Shopping Ambulating Bed Mobility Stair Climbing Cooking Bathing Transferring Assistive Devices Housekeeping Medical Equipment (In-Patient): (Trapeze, CPM, Special Mattresses/Beds, IV Pumps, Tube Feeding Pumps) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Medical Equipment for Discharge: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
