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ADULT ASSESSMENT TOOL

I.

GENERAL DATA Name: Age: Sex: Birthplace: Religion: Present address: N m!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: D ration: &re, enc#: Intermittent(edications ta.en: Inter*entions gi*en: /as it relie*edAggra*ating "actors:

Alle*iating "actors: Associated signs and s#mptoms: $ons ltations: I0. RE0IE/ '& S)STE(S $ardio*asc lar: 1 2 orthopnea General: 1 2 3eight loss 1 2 3eight gain 1 2 decrease in acti*it# 1 2 appetite 1 2 dela# in gro3th Respirator#: 1 2 co gh 1 2 di""ic lt# o" !reathing $ taneo s: 1 2 rash 1 2 pigmentation 1 2 hair loss 1 2 acne 1 2 pr rit s 1 2 se o" accessor# m scles 1 2 retractions: location: Gastrointestinal: 1 2 *omiting 1 2 !o3el mo*ements 1 2 a!dominal pain 1 2 5a ndice %ead: 1 2 headache 1 2 di44iness 1 2 *is al di""ic lties 1 2 lacrimation 1 2 hearing 1 2 a ral discharge 1 2 nasal discharge 1 2 epistaxis 1 2 toothache 1 2 sali*ation 1 2 sore throat Endocrine: 1 2 !reast as#mmetr# Genito rinar#: $olor o" rine: 1 2 ! rning sensation 1 2 "re, enc# 1 2 discharge 1 2 en resis 1 2 edema o" hands and "eet 1 2 menstr al periods 1 2 "ood intolerance 1 2 c#anosis 1 2 eas# "atiga!ilit# 1 2 "ainting spells

1 2 sleep pro!lems 1 2 cold intolerance 1 2 heat intolerance 1 2 pol# ria 1 2 pol#dipsia

1 2 mood changes

( sc los.eletal: 1 2 pain in !one 1 2 pain in 5oint 1 2 pain in m scle

Ner*o s6 Beha*ioral: 1 2 sleep pro!lems 1 2 3ea.ness 1 2 paral#sis 1 2 memor# loss

1 2 s3elling

%ematopoeitic: 1 2 pallor 1 2 !leeding mani"estations

0. PAST (EDI$AL %IST'R) (a5or medical illnesses: (a5or s rgical illnesses: Tra ma6&ract res: Age Date Remar.s

Pre*io s hospital admissions: $ rrent *itamins6 "ood s pplements6 her!al s pplements: $ rrent medications: 7no3n allergies to "ood and dr gs: 8. &A(IL) %IST'R) A. Parents . B. Si!lings Age 'cc pation6Le*el o" Ed cation State o" %ealth

$. &amilial illness or anomalies:

Is there a histor# o" consang init#8I. S'$I'E$'N'(I$ AND EN0IR'N(ENTAL %IST'R) A. Li*ing $irc mstances

Place and nat re o" d3elling: %o se made o": 0entilation: No. o" 3indo3s: So rce o" 3ater "or drin.ing: So rce o" 3ater "or 3ashing: T#pe and location o" toilet: /here do the# sleepAre there appliancesN m!er o" persons li*ing in the ho se: Relationships among ho sehold mem!ers:

B. Economic $irc mstances (em!ers o" the "amil# 3ho 3or.: Income: So rce o" " nds: N m!er o" meals per da#: &ood comprised mainl# o":

$. En*ironmental $irc mstances Expos re to poll tants %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

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