Assignment 3 - Patient Assessment Sheet

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Interview date: Admission date (hospital/rest home patients) NB: put n/a for not applicable where appropriate Surname: Address: First Name: Mr. Mrs day: night: cell: Miss Dr other

Age:

Date of Birth:

Male / Female

Ethnicity:

Living: Alone / Spouse / Partner / Family / Residential Home / Other details: Occupation: Support: Family / District Nurse / Care giver/Other Details: Contact Name: Smoker: N / Y how many?. Gave up after .. yrs Doctor: Other Medical Support: Alcohol: N / Y .per week Tea N / Y qty BMI (wt in kg (height in metres)2) General health: Children: no.: Interests : good / average / poor Ages

Daily fluid intake: Water N / Y qty Coffee N / Y qty Height: Nutrition: Weight good / average / poor

(also assess other caffeinated drinks e.g. Coca Cola)

Pregnant / Breastfeeding? Exercise/Activity:? Sports Family History: Who: Allergies: Hobbies

Diabetes / Asthma / CHD / Epilepsy / Cancer/ Other ? Parent / Sibling / Grandparent / Child / Details ?

Medicines: Food: Other:

Adverse Drug Reactions: Drug Type of reaction (if known)

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ASSIGNMENT 3 - PATIENT ASSESSMENT SHEET

Current Medical Conditions
Condition Cardiovascular disease e.g angina, CHD Gastrointestinal disease e.g GORD Respiratory disease e.g. asthma, COPD Musculoskeletal disease eg. Arthritis Pain CNS / neuro Psychiatric Other Previous Medical History (including surgery): Since When Details

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Degree of symptom Control

Issues related to taking medicinesReading labels on the medicines bottle Opening the containers Getting tablets out of the foil or bottleN Swallowing the tablets Remembering to take the medicines Compliance Issues?

Does the patient have difficulties: N Y Comment . N Y N N Y Comment

Comment Y Y Comment Comment

General comments / patient concerns /expectations about medicines:

LAB RESULTS / OBSERVATIONS

LAB RESULTS Range
135-146mmol/L 3.5-5.0 mmol/L 0.05-0.12 mmol/L 3.2-7.7 mmol/L 0.75-1.00mmol/L 2.17-2.64mmol/L 1.15-2.15mmol/L 35-47g/L 0-60U/L 40-110U/L < 40U/L < 45U/L 2-20 umol/L 125-170g/L 80-100fL 4-10 X10E9/L 2.0-7.5 X10E9/L 150-400 X10E9/L 1-30mm/hr 3.0 - 5.6 mmo/L(Fasting) 5.5 7 (age dependent) < 4mmol/l > 1 mmol/l < 4.5 < 2mmol/l < 2.5 mmol/l

Date

Value

Date

Value

Date

Value

Na K Cr Urea Mg Ca
Phosp Albumin GGT

ALP AST ALT Bilirubin Hb MCV WCC Neutro Platelets ESR Glucose HbA1c Cholesterol HDL Chol:HDL Triglycerides LDL other
OBSERVATIONS

BP HR Temp Peak flow other

Current Prescription Medicines

As at (date):

Drug

Form/Strength/ route

Dose

Freq

Date started

Purpose

Effectiveness

Comment

OTC / Complementary medicines

Medicine Form/Strength/ route Dose Freq Date started Purpose Effectiveness Comment

Recently discontinued medicines

Medicine Dose Freq Date started Purpose Date stopped Reason for stopping