CLINICAL WORKSHEET
Student Name:____________________________
Client Information:
Initials:_________ Age:______
Gender:_____
Date:________________
Medical Diagnosis:
Ethnicity:__________
Spiritual Beliefs:_______________________
Height:________
Past Medical History:
Weight:_______
Allergies (in red ink):
Vital Signs:
Past Surgeries/Procedures:
Temperature: _____ Pulse: _____
Respirations:_____
Developmental Stage According to Erikson:
BP (left/right): _______ _______
Describe the Pathophysiology of this Client’s Diagnosis:
Diet:
Activity:
Type:________________________________
Intake & Output:
Miscellaneous:
TIME MANAGEMENT PLAN
1
List the various activities you will be engaged in during your day. Include client care
activities such as preconference, bathing, assisting with eating, etc…. Also include time you
plan to take lunch break.
TIME
ACTIVITY
0630
0700
0800
0900
1000
1100
1200
1300
1400
SELF ASSESSMENT:
(Describe your time management for the day (identify areas of strengths and weaknesses).
Describe how you will modify plan for next week.
2