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ADULT ASSESSMENT TOOL

I. GENERAL DATA

Name:

Age:

Sex:

Birthplace:

Religion:

Present address:

Nm!er and date o" hospital admissions:

Name o" in"ormant and relation to patient:

Relia!ilit# o" in"ormant in percentage:

II. $%IE& $'(PLAINT

III. %IST'R) '& PRESENT ILLNESS

S#mptom:

'nset:

Time:

(anner:

Se*erit#:

+alit#:

Location:

Dration:

&re,enc#:

Intermittent-

(edications taen:

Inter*entions gi*en:

/as it relie*ed-

Aggra*ating "actors:

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Alle*iating "actors:

Associated signs and s#mptoms:

$onsltations:

I0. RE0IE/ '& S)STE(S

General:

1 2 3eight loss

1 2 3eight gain

1 2 decrease in acti*it#

1 2 appetite

1 2 dela# in gro3th

$taneos:

1 2 rash

1 2 pigmentation

1 2 hair loss

1 2 acne

1 2 prrits

%ead:

1 2 headache

1 2 di44iness

1 2 *isal di""iclties

1 2 lacrimation

1 2 hearing

1 2 aral discharge

1 2 nasal discharge

1 2 epistaxis

1 2 toothache

1 2 sali*ation

1 2 sore throat

$ardio*asclar:

1 2 orthopnea

1 2 c#anosis

1 2 eas# "atiga!ilit#

1 2 "ainting spells

Respirator#:

1 2 cogh

1 2 di""iclt# o" !reathing

1 2 se o" accessor# mscles

1 2 retractions: location:

Gastrointestinal:

1 2 *omiting

1 2 !o3el mo*ements

1 2 a!dominal pain

1 2 5andice

1 2 "ood intolerance

Genitorinar#:

$olor o" rine:

1 2 !rning sensation

1 2 "re,enc#

1 2 discharge

1 2 enresis

1 2 edema o" hands and "eet

1 2 menstral periods

Endocrine:

1 2 !reast as#mmetr#

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1 2 sleep pro!lems

1 2 cold intolerance

1 2 heat intolerance

1 2 pol#ria

1 2 pol#dipsia

Ner*os6 Beha*ioral:

1 2 sleep pro!lems

1 2 3eaness

1 2 paral#sis

1 2 memor# loss

1 2 mood changes

(scloseletal:

1 2 pain in !one

1 2 pain in 5oint

1 2 pain in mscle

1 2 s3elling

%ematopoeitic:

1 2 pallor

1 2 !leeding mani"estations

0. PAST (EDI$AL %IST'R)

(a5or medical illnesses: Age Date Remars

(a5or srgical illnesses:

Trama6&ractres:

Pre*ios hospital admissions:

$rrent *itamins6 "ood spplements6 her!al spplements:

$rrent medications:

7no3n allergies to "ood and drgs:

8. &A(IL) %IST'R)

A. Parents Age 'ccpation6Le*el o" Edcation State o" %ealth

.

B. Si!lings

$. &amilial illness or anomalies:

Is there a histor# o" consanginit#-

8I. S'$I'E$'N'(I$ AND EN0IR'N(ENTAL %IST'R)

A. Li*ing $ircmstances

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Place and natre o" d3elling:

%ose made o":

0entilation: No. o" 3indo3s:

Sorce o" 3ater "or drining:

Sorce o" 3ater "or 3ashing:

T#pe and location o" toilet:

/here do the# sleep-

Are there appliances-

Nm!er o" persons li*ing in the hose:

Relationships among hosehold mem!ers:

B. Economic $ircmstances

(em!ers o" the "amil# 3ho 3or:

Income:

Sorce o" "nds:

Nm!er o" meals per da#:

&ood comprised mainl# o":

$. En*ironmental $ircmstances

Exposre to polltants

%ealth condition in the neigh!orhood

1 2 congested6 cro3ded area

8II P%)SI$AL E8A(INATI'N

A. General $ondition and Appearance

B. 0ital Signs