* = Required Information
Vitals:

Glasses
Hearing Aid
Dentures
Cane
Electric Cart/scooter
Walker
Oxygen
Assistive Dressing
Wheelchair Devices
Other
Yes No Other
Diagnosis:
Vaccination Status:
Yes No
Yes No
Sensory Losses and Communication Problems:
Glaucoma Cataracts Macular Degeneration

ADLs

Dressing


Toileting


Bathing


Hair Care


Oral Hygiene


Shaving


Eating


Transferring


Mobility


Self-Preservation

IADLs

Telephone


Finances


Shopping


Laundry


Housekeeping


Food Preparation


Appointments


Transportation


Rash
Itching
Cool
Pale
Moist
Flushed
Open Sores
Cellulitis
Other

Thyroid
Diabetes
Hyperglycemia
Hypoglycemia
Other

Thyroid
Parkinson’s
Headaches
Paralysis
TIA’s
Dizziness
Seizures
Other

Thyroid
Constipation
Gastric reflux
Diarrhea
Nausea/Vomiting
Bowel Incontinence
Other

Heart Disease
High Blood Pressure
Chest Pain Heart Attack
Pacemaker
Other

Urinary Incontinence

Shortness of Breath
Cough Bronchitis
Pneumonia
Emphysema Smoker/History of Smoking
Asthma
Other

Shortness of Breath
Joint Replacement
Arthritis Osteoporosis
Pain
Other

Alert
Oriented to
Sad/Depressed
Confused Wanders
Paranoid
Impaired Decision-making
Mental illness or cognitive impairment diagnosis
Behavior issues (verbal or physical aggression)
Other


Afraid of falling
Has fallen in past year
Sleep patterns
Frequent Hospitalizations
Cancer
Alcohol/controlled substance use
Other

Over-the-Counter, Herbal and Prescribed Medications (if possible, do a “brown bag” assessment):

RN Evaluation/Initial Assessment Completed within 5 days of admission by:

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