When planning a patient’s care, nursing assessment forms come in handy in establishing the baseline data and the health condition of the patient. The nursing assessment form can be either in form of a questionnaire or a checklist. The assessment form is easy to understand and to fill. Here is a sample nursing assessment form.
Nursing Assessment Form
Patient name: _____________________________ Patient Number ______________
Care taker / Nurse name: ____________________________ Phone _________________
ASSISTIVE DEVICES (indicate YES to all devices that apply)
Hearing aid(s) ___________ Glasses ___________ Contacts ___________
Crutches ___________ Walker ___________ Cane ___________
Wheelchair ___________ others (specify) ________________________________
PSYCHOSOCIAL/COPING
Primary Language: _____________________ Interpreter required? _____________
Whom do you live with? ___________________________________________________
Any family members (or others) that information should be shared with? (List names)
_________________________________ _________________________________
_________________________________ _________________________________
_________________________________ _________________________________
Is there family member willing and able to assist with healthcare, at home? _____________
Have you had sleeping problems? ____________________
Would you like assistance with or information regarding: (indicate all that apply)
Complementary therapies and cancer support group’s ___________________
Financial support and family counseling concerns ______________________
Nutrition supplies and medical equipment issues _______________________
Household help, meal preparation or spiritual support ___________________
Workplace issues and transportation concerns _________________________
Referral Made _________________________ to __________________________________
Assessment Mode: ________________________ By: ______________________________
Signature: ______________________________ Date: ____________________________
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