Professional Documents
Culture Documents
NUR 111
Assessment Guide
Student Name:________________ Client Initials:_____________ Date:__________
General Appearance/Survey
Age:
Gender:
Height:
Weight:
________
________
________
________
Gait:
_________
Posture:
_________
Speech:
_________
Affect:
_________
Other:________________________________________________________________________
_________________________________________________________________
Vital Signs:
T:
_________
O2 Sat: _________
P:__________
R:_________
B/P:________
Pain: Y or N
Onset-_________________________________
Location-_______________________________
Duration-_______________________________
Quality-________________________________
Intensity-_______________________________
Past Medial History:
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________
Past Surgical History:
_____________________________________________________________________________
_____________________________________________________________________________
__
Current Medications: (name, dose, route, frequency)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
____
Allergies: (medications, food, others & type of reaction)
_____________________________________________________________________________
_____________________________________________________________________________
__
_____________________________________________________________________________
_
Integumentary
I.
II.
III.
The Head
I.
II.
III.
IV.
V.
VI.
Neck
I.
II.
III.
IV.
V.
III.
IV.
Abdomen
I.
II.
III.
IV.
Musculoskeletal
Neurological
I.
II.
III.
IV.
V.
VI.
Genitals
I.
II.
III.
IV.
Additional Notes: