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ADMISSION ASSESSMENT

Personal Details

Speaks English Yes

No

__________

Aphasic

No

__________

Yes

Speech Impediment
Yes
__________

No

Surname
_____________________________________

Sensory

Comment

First name
____________________________________

Hearing Impaired
Yes
__________

No

Male ________________ Female


_________________

Visually Impaired
Yes
__________

No

Date Of Birth ___________________ Age


__________

Amputation

Yes

No

__________

Hemiplegia

Yes

No

__________

Paraplegia

Yes

No

__________

Date______________Time_______________

Address _____________________________________
Phone Number
_______________________________

Diet/Nutrition

Date______________Time_______________

Diet at
Home__________________________________

Baseline Data:
Ht____Wt_____T____P____RR____BP____
Admitted from: Home____ER____Other____
Mode of Transport:
Stretcher____W/C____Amb____

Appetite_____________________________________
_

Skin

Allergies
Substance

Likes/Dislikes________________________________
__

Warm/Dry
___________________________

Type f Reaction ___________________________

Mental Status

Comment

Alert/Oriented

Yes

No

__________

Confused

Yes

No

__________

Anxious

Yes

No

__________

Comatose

Yes

No

__________

Combative

Yes

No

__________

Other________________________________________

Comment

Yes

No

__________

Abrasions/Bruises
Yes
__________

No

Laceration/Scar Yes

No

__________

Reddened Areas Yes

No

__________

Decubitus Ulcers
Yes
__________

No

Burns

Yes

No

__________

Rash/Scaling

Yes

No

__________

Diaphoretic

Yes

No

__________

Other________________________________________
_
Color:

Communication

Location

Pale

Normal Cyanotic

Treatments in Progress
_____________________________________________
_____________________________________________
_____________________________________________

ADMISSION ASSESSMENT
Elimination

Comment

GI: Constipation Yes

No

__________

Frequency

Yes

No

__________

Laxatives

Yes

No

__________

Other________________________________________
_

Bathing
__________

Yes

No

Dressing
__________

Yes

No

Eliminating
__________
Turning
__________

No

__________

Glasses

Yes

No

__________

Contact Lenses Yes

No

__________

Yes

No

__________

Burning

Yes

No

__________

Personal Habits:

Incontinent

Yes

No

__________

Tobacco use
__________

No

No

Yes

No

Unable to fall asleepYes

Yes

Denture

Yes

Sleeping

No

Other________________________________________

GU: Frequency

Other_______________________________________

Yes

Comment

(quantity)

__________

Awakens frequently
Yes
__________

No

Alcohol use
__________

Sleep meds

Yes

No

__________

(quantity)

Naps

Yes

No

__________

Chief_Complaint:____________________________
_____________________________________________
_____________________________________________
___

ADL

Comment

Assistance needed for:


Ambulation

Yes

No

Eating
__________

Yes

No

__________

Yes

No

Other_Assessment_Data:_____________________
_____________________________________________
_____________________________________________
____