Date _____

Name _____

Room _____

Sex: M F

Address _____

Telephone number _____

Private home _____

Apartment _____

Retirement center _____

Nursing facility _____

Date of birth _____

Age _____

Date of admission _____

Date of surgery _____

Marital status: M W S D

If widowed, how long? _____

Retired _____

Occupation _____

Medicare number _____

Medicaid number _____

Insurance name _____

Number _____

Religious preference _____

Contact in emergency _____

Reason for seeking care (chief complaint) _____

History of present illness/condition/surgery _____

Patient's understanding of current condition _____

Current diet __________

Medications currently prescribed _____

Past health/medical history_____

Allergies (food, medicines, environmental) _____

Medications and treatments at home _____

Chemical use

Number of cigarettes per day _____

Other tobacco per day _____

Number of years smoked _____

Amount of coffee/tea/carbonated beverages per day _____

Amount of alcoholic drinks per day _____

Type _____

Use of other substances _____

Rest and sleep patterns

Hours worked per day _____

Rest periods or naps (when, _____ )

Hours of sleep per night _____

Medications used to aid sleep _____

Other measures to aid sleep _____

Sleep problems _____

Mobility and exercise patterns

Type of activity/exercise _____

Amount (times per week, minutes per day) _____

Restrictions/mechanical aids/prostheses/wheelchair/walker/bedrails _____

Ability to care for self _____

Diet

24-hour recall of previous day

Breakfast _____

Lunch _____

Dinner _____

Snacks _____

Usual time of meals at home

Breakfast _____

Lunch _____

Dinner _____

Snacks _____

Ability to feed self _____

Dentures _____

Dietary restrictions/dislikes, difficulty _____

Fluid intake per day (type and amount) _____

Elimination routines, frequency, problems, aids

Bowel _____

Urinary _____

Communication

Ability to understand English _____

Language spoken _____

Hearing _____

Sight _____

Aids _____

Educational level _____

Ability to speak _____

Orientation

Person _____

Time _____

Place _____

Present emotional state _____

Activities

Hobbies _____

Part-time employment _____

Volunteer work _____

Other _____

Family history

Composition

Number in household

Roles

Primary support system

History of family health/illness

Other pertinent data

Environmental history

Review of Systems