| TITLE |
FIRST NAME |
SURNAME |
LOCATION SEEN AT |
ASSESSOR |
| . |
|
|
|
|
| ASSESSMENT DATE |
|
DATE OF BIRTH |
|
NAMED NURSE |
|
ADDRESS
OF PATIENT |
|
TEL |
|
| NEXT OF KIN |
|
RELATIONSHIP |
|
ADDRESS
. |
|
TEL |
|
MEDICAL HISTORY |
DOCTOR |
|
TEL |
|
| DIAGNOSIS |
|
| COMMENTS |
|
| MEDICATION |
|
| ALLERGIC TO |
|
| REASON FOR ADMISSION |
|
| DSS LA AA |
|
| INFORMATION GIVEN |
|
| PAST OCCUPATION |
|
| MOBILITY |
|
| PERSONAL CARE |
|
| MENTAL ALERTNESS |
|
| ANXIETIES |
|
| SMOKING |
|
| DIET |
|
| CONTINENCE |
|
| RELIGION |
|
EQUIPMENT
| WHEELCHAIR |
ZIMMER |
DENTURES TOP |
DENTURES BTM |
SPECTACLES |
HEARING AID |
. |
|
|
|
|
|
HOSPITAL HISTORY |
HOSPITAL |
|
TEL |
|
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