Professional Documents
Culture Documents
Student: Date:
Assessment Guide
Instructions: Complete the assessment guide on the day of assessment. No Blanks! May use N/A for not applicable. Star (*) significant data in red.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Presenting Problem (What led the client to seek treatment? History of the current problem onset, symptoms, severity,
duration):
Home Medications:
Frequency Drug
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
PHYSICAL
Integumentary (general appearance of skin):
Sensory Neurological (seizures, headaches, etc) Cardiovascular Respiratory B/P _____________ P ____________ (rhythm _________)
R _________
Gastrointestinal (GI) Usual Diet/Favorite foods Ordered Diet Food Allergies Dental Health Nutritional Status IBW __________________ Recent loss/gain Genitourinary (GU) /Reproductive Sexual Dysfunction Urinary Elimination Pattern Bowel Elimination Pattern Musculoskeletal (muscle tone/strength, motor ability, tremors, etc) Last BM GI Complaints Current Weight ______________
(Lab tests used to monitor therapeutic blood levels of Depakote, Lithium, anticonvulsants, etc;
WBC with Clozaril, liver studies on alcoholics, tests to rule out thyroid disorder, etc.) Date Lab Test Results Significance
Speech Patterns
Emotions
General Attitude
Thought Processes
Perception
Memory
Impulse Control
Who is the most important person in your life? Are people available to you when you are in need? Who/what provides you with strength and hope?
Currently Employed?
Health Beliefs and Practices (personal responsibility for health; special self-care practices)
Significant Losses/Changes (include approximate date and note how this affects behavior) {Stage of Grief: N/A denial anger bargaining depression acceptance}
Sad
Angry
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Dress Expressed Feelings of Inferiority Willingness to Initiate Conversation Participation (group activities, interactions with staff/other clients, etc)
Charting Day 1:
Charting Day 2: