ADMISSION ASSESSMENT HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

DEMOGRAPHIC DATA Date: ______________ Time: ______________ OBJECTIVE

Name: _______________________________________________________ 1. Mental Status (indicate assessment with a )
Date of Birth: _________________________ Age: ________ Sex: ________ a. Oriented__ Disoriented__
Primary significant other: ____________________ Telephone: ___________ Time: Yes__ No__; Place: Yes__ No__; Person: Yes__ No__;
Name of primary information source: _______________________________ b. Sensorium
Admitting medical diagnosis:______________________________________ Alert__ Drowsy__ Lethargic__ Stuporous__ Comatose__
Cooperative__ Combative__ Delusional__
VITAL SIGNS: c. Memory
Temperature: ____F ____C ; oral__ rectal __ axillary __ tympanic __ Recent: Yes__ No__; Remote: Yes__ No__
Pulse Rate: ____bpm; radial __ apical ___; regular ___ irregular __
Respiratory Rate: ___cpm; abdominal ___ diaphragmatic ___ 2. Vision
Blood Pressure: left arm ___ right arm___; a. Visual acuity: Both eyes 20/___; Right 20/___; Left 20/___; Not
standing__ sitting__ lying down ___ assessed___
Weight: __ pounds; ___kg b. Pupil size: Right: Normal__ Abnormal__;
Height: ___feet ___inches; ___meters Left: Normal__ Abnormal__
c. Pupil reaction: Right: Normal__ Abnormal__;
Do you have any allergies? No__ Yes__ What?! ________________ Left: Normal__ Abnormal__
(Check reactions to medications, foods, cosmetics, insect bites, etc.)
3. Hearing
Review admission CBC, urinalyses and chest-xray. Note any abnormalitites a. Not assessed__
here: ________________________________________________________ b. Right ear: WNL__ Impaired__ Deaf__; Left ear: WNL__ Impaired__
_____________________________________________________________ Deaf__
c. Hearing aid: Yes__ No__

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4. Taste ________________________________________________________
a. Sweet: Normal__ Abnormal__ Describe:______________________ _
b. Sour: Normal__ Abnormal__ Describe:_______________________
c. Tongue movement: Normal__ Abnormal__ Describe:____________ 9. Reflexes: Normal__ Abnormal__ Describe: ______________________
d. Tongue appearance: Normal__ Abnormal__ Describe:___________ ________________________________________________________
5. Touch _
a. Blunt: Normal__ Abnormal__ Describe:_______________________
b. Sharp: Normal__ Abnormal__ Describe:______________________ 10. Any enlarged lymph nodes in the neck? No__ Yes__ Location and size:
c. Light touch sensation: Normal__ Abnormal__ Describe:__________ ________________________________________________________
d. Proprioception: Normal__ Abnormal__ Describe:________________ _
e. Heat: Normal__ Abnormal__ Describe:_______________________ ________________________________________________________
f. Cold: Normal__ Abnormal__ Describe:________________________ _
g. Any numbness? No__ Yes__ Describe:_______________________
h. Any tingling? No__ Yes__ 11. General appearance:
Describe:__________________________ a. Hair: __________________________________________________
b. Skin: __________________________________________________
6. Smell c. Nails: _________________________________________________
a. Right nostril: Normal__ Abnormal__ Describe:__________________ d. Body odor: _____________________________________________
b. Left nostril: Normal__ Abnormal__ Describe:___________________
SUBJECTIVE
7. Cranial Nerves: Normal__ Abnormal__ Describe deviations:_________ 1. How would you describe your usual health status?
________________________________________________________ Good__ Fair__ Poor__
_ 2. Are you satisfied with your usual health status?
Yes__ No__ Source of dissatisfaction: ____________________________
8. Cerebellar Exam (Romberg, balance, gait, coordination, etc.) 3. Tobacco use? No__ Yes__ Number of packs per day? _______________
Normal__ Abnormal__ Describe:______________________________ 4. Alcohol use? No__ Yes__ How much and what kind? ________________
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5. Street drug use? No__ Yes__ What and how much? _________________ Name Dosage Times/Da Reason Taken as Ordered
6. Any history of chronic disease? No__ Yes__ Describe: _______________ y
___________________________________________________________ Yes__ No__
7. Immunization history: Tetanus__ Pneumonia__ Influenza__ MMR__
Polio__ Hepatitis B__
8. Have you sough any health care assistance in the past year? No__ Yes__ 13. Have you followed the routine prescribed for you?
If yes, why? _________________________________________________ Yes__ No__ Why not? ______________________________________
9. Are you currently working? No__ Yes__ How would you rate your working 14. Did you think this prescribed routine was best for you?
conditions? (e.g. safety, noise, space, heating, cooling, water, Yes__ No__ What would be better? ____________________________
ventilation)? Excellent__ Good__ Fair__ Poor__ Describe any problem 15. Have you had any accidents/injuries/falls in the past year?
areas:______________________________________________________ No__ Yes__ Describe: ______________________________________
10. How would you rate living conditions at home? 16. Have you had any problems with cuts healing?
Excellent__ Good__ Fair__ Poor__ Describe any problem areas: No__ Yes__ Describe: ______________________________________
________________ 17. Do you exercise on a regular basis?
__________________________________________________________ No__ Yes__ Type & Frequency: ______________________________
11. Do you have any difficulty securing any of the following 18. Have you experienced any ringing in the ears: Right ear: Yes__ No___
services? Left ear: Yes__ No__
Grocery store: Yes:__ No:__; Pharmacy: Yes__ No__; Health Care 19. Have you experienced any vertigo: Yes__ No__ How often and when?
Facility: Yes:__ No:__; Transporation: Yes:__ No:__; Telephone (for ________________________________________________________
police, fire, ambulance): Yes:__ No:__; If any difficulties, note referral _
here: ______________________________________________________ 20. Do you regularly use seat belts? Yes__ No__
__________________________________________________________ 21. For infants and children: Are car seats used regularly? Yes__ No__
22. Do you have any suggestions or requests for improving your health?
12. Medications (over-the-counter and prescription) Yes__ No__ Describe: ______________________________________
________________________________________________________
_
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23. Do you do (breast/testicular) self-examination? No__ Yes__ NUTRITIONAL-METABOLIC PATTERN
How often? _______________________________________________
OBJECTIVE
1. Skin examination
a. Warm__ Cool__ Moist__ Dry__
b. Lesions: No__ Yes__ Describe: _______________________________
c. Rash: No__ Yes__ Describe: _________________________________
d. Turgor: Firm__ Supple__ Dehydrated__ Fragile__
e. Color: Pale__ Pink__ Dusky__ Cyanotic__ Jaundiced__ Mottled__
Other____________________________________________________

2. Mucous Membranes
a. Mouth
i. Moist__ Dry__
ii. Lesions: No__ Yes__ Describe: __________________________
iii. Color: Pale__ Pink__
iv. Teeth: Normal__ Abnormal__ Describe:____________________
v. Dentures: No__ Yes__ Upper__ Lower__ Partial__
vi. Gums: Normal__ Abnormal__ Describe:____________________
vii. Tongue: Normal__ Abnormal__ Describe:___________________

b. Eyes
i. Moist__ Dry__
ii. Color of conjunctiva: Pale__ Pink__ Jaundiced__
iii. Lesions: No__ Yes__ Describe:___________________________

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3. Edema SUBJECTIVE:
a. General: No__ Yes__ 1. Any weight gain in the last 6 months? No__ Yes__ Amount: ___________
Describe:_______________________________ 2. Any weight loss in the last 6 months? No__ Yes__
Abdominal girth: ___inches Amount:____________
b. Periorbital: No__ Yes__ 3. How would you describe your appetite? Good__ Fair__ Poor__
Describe:_____________________________ 4. Do you have any food intolerance? No__ Yes__ Describe: ____________
c. Dependent: No__ Yes__ 5. Do you have any dietary restrictions? (Check for those that are a part of a
Describe:_____________________________ prescribed regimen as well as those that patient restricts voluntarily, for
Ankle girth: Right:__ inches; Left__inches example, to prevent flatus) No__ Yes__ Describe:
___________________
4. Thyroid: Normal__ Abnormal__ Describe: _________________________ ___________________________________________________________
5. Jugular vein distention: No__ Yes__ 6. Describe an average day’s food intake for you (meals and snacks): _____
6. Gag reflex: Present__ Absent__ ___________________________________________________________
7. Can patient move easily (turning, walking)? Yes__ No__ ___________________________________________________________
Describe limitations: __________________________________________ 7. Describe an average day’s fluid intake for you. _____________________
8. Upon admission, was patient dressed appropriately for the weather? ___________________________________________________________
Yes__ No__ Describe: ________________________________________ 8. Describe food likes and dislikes. _________________________________
___________________________________________________________
For breastfeeding mothers only: 9. Would you like to: Gain weight?__ Lose weight?__ Niether__
10. Any problems with:
9. Breast exam: Normal__ Abnormal__ a. Nausea: No__ Yes__ Describe: _______________________________
Describe:______________________ b. Vomiting: No__ Yes__ Describe: ______________________________
___________________________________________________________ c. Swallowing: No__ Yes__ Describe: ____________________________
10. If mother is breastfeeding, have infant weighed. Is d. Chewing: No__ Yes__ Describe: ______________________________
infant’s weight within normal limits? Yes__ No__ e. Indigestion: No__ Yes__ Describe: ____________________________

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11. Would you describe your usual 3. Rectal Exam:
lifestyle as: Active__ Sedate__ a. Sphincter tone: Describe: ____________________________________
b. Hemorrhoids: No__ Yes__ Describe: ___________________________
For breastfeeding mothers only: c. Stool in rectum: No__ Yes__ Describe: _________________________
12. Do you have any concerns about d. Impaction: No_- Yes__ Describe:______________________________
breast feeding? No__ Yes__ Describe: e. Occult blood: No__ Yes__ Location: ___________________________
___________________________________________________
13. Are you having any problems with 4. Ostomy present: No__ Yes__ Location: ___________________________
breastfeeding? No__ Yes__ Describe:
___________________________________________________ SUBJECTIVE
1. What is your usual frequency of bowel movements? _________________
ELIMINATION PATTERN a. Have to strain to have a bowel movement? No__ Yes__
b. Same time each day? No__ Yes__
OBJECTIVE
1. Auscultate abdomen: 2. Has the number of bowel movements changed in the past week?
a. Bowel sounds: Normal__ Increased__ Decreased__ Absent__ No__ Yes__ Increased?__ Decreased?__

2. Palpate abdomen: 3. Character of stool

a. Tender: No__ Yes__ Where?_________________________________ a. Consistency: Hard__ Soft__ Liquid__
b. Soft: No__ Yes__; Firm: No__ Yes__ b. Color: Brown__ Black__ Yellow__ Clay-colored__
c. Masses: No__ Yes__ Describe: _______________________________ c. Bleeding with bowel movements: No__ Yes__
d. Distention (include distended bladder): No__ Yes__ Describe: _______
________________________________________________________ 4. History of constipation: No__ Yes__ How often?
_ ____________________
e. Overflow urine when bladder palpated? Yes__ No__ Do you use bowel movement aids (laxatives, suppositories, diet)?
No__ Yes__ Describe:_________________________________________
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 1. Cardiovascular
5. History of diarrhea: No__ Yes__ When?___________________________ a. Cyanosis: No__ Yes__ Where? _______________________________

6. History of incontinence: No__ Yes__ Related to increased abdominal b. Pulses: Easily palpable?
pressure (coughing, laughing, sneezing)? No__ Yes__ Carotid: Yes__ No__; Jugular: Yes__ No__; Temporal: Yes__ No__
Radial: Yes__ No__; Femoral: Yes__ No__; Popliteal: Yes__ No__;
7. History of travel? No__ Yes__ Where?____________________________ Postibial: Yes__ No__; Dorsalis Pedis: Yes__ No__

8. Usual voiding pattern: c. Extremities:

a. Frequency (times per day) ____ Decreased?__ Increased?__ i. Temperature: Cold__ Cool__ Warm__ Hot__
b. Change in awareness of need to void: No__ Yes__ Increased?__ ii. Capillary refill: Normal__ Delayed__
Decreased?__ iii. Color: Pink__ Pale__ Cyanotic__ Other__ Describe: __________
c. Change in urge to void: No__ Yes__ Increased?__ Decreased?__ ____________________________________________________
d. Any change in amount? No__ Yes__ Increased?__ Decreased?__ iv. Homan’s sign: No__ Yes__
e. Color: Yellow__ Smokey__ Dark__ v. Nails: Normal__ Abnormal__ Describe: _____________________
f. Incontinence: No__ Yes__ When? _____________________________ vi. Hair distribution: Normal__ Abnormal__ Describe: ____________
Difficulty holding voiding when urge to void develops? No__ Yes__ ____________________________________________________
Have time to get to bathroom: Yes__ No__ How often does problem vii. Claudication: No__ Yes__ Describe: _______________________
reaching bathroom occur? ___________________________________ ____________________________________________________
g. Retention: No__ Yes__ Describe: _____________________________
h. Pain/burning: No__ Yes__ Describe: ___________________________ d. Heart: PMI location: ________
i. Sensation of bladder spasms: No__ Yes__ When? ________________ i. Abnormal rhythm: No__ Yes__ Describe: ___________________
____________________________________________________
ACTIVITY-EXERCISE PATTERN ii. Abnormal sounds: No__ Yes__ Describe: ___________________
____________________________________________________
OBJECTIVE
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2. Respiratory Left: Normal__ Decreased__
a. Rate:__ Depth: Shallow__ Deep__ Abdominal__ Diaphragmatic__ g. Postural: Normal__ Kyphosis__ Lordosis__
b. Have patient cough. Any sputum? No__ Yes__ Describe: ___________ h. Deformities: No__ Yes__ Describe: ____________________________
________________________________________________________ i. Missing limbs: No__ Yes__ Where?
_ ____________________________
c. Fremitus: No__ Yes__ j. Uses mobility aids (walker, crutches, etc)? No__ Yes__ Describe: ____
d. Any chest excursion? No__ Yes__ Equal__ Unequal__ ________________________________________________________
e. Auscultate chest: _
i. Any abnormal sounds (rales, rhonchi)? No__ Yes__ Describe: __ k. Tremors: No__ Yes__ Describe: ______________________________
____________________________________________________ ________________________________________________________
f. Have patient walk in place for 3 minutes (if permissible): _
i. Any shortness of breath after activity? No__ Yes__ 4. Spinal cord injury: No__ Yes__ Level: ____________________________
ii. Any dypnea? No__ Yes__ 5. Paralysis present: No__ Yes__ Where? ___________________________
iii. BP after activity: ___/___ in (right/left) arm 6. Developmental Assessment: Normal__ Abnormal__ Describe: _________
iv. Respiratory rate after activity: _______ ___________________________________________________________
v. Pulse rate after activity: _______
SUBJECTIVE
3. Musculoskeletal
a. Range of motion: Normal__ Limited__ Describe: __________________ 1. Have patient rate each area of self-care on a scale of 0 to 4. (Scale has
b. Gait: Normal__ Abnormal__ Describe: __________________________ been adapted by NANDA from E. Jones, et. Al., Patient Classification for
c. Balance: Normal__ Abnormal__ Describe: ______________________ Long Term Care; User’s Manual. HEW Publication No. HRA-74-3107,
d. Muscle mass/strength: Normal__ Increased__ Decreased__ November 1974.)
Describe: ________________________________________________ 0 – Completely independent
e. Hand grasp: Right:: Normal__ Decreased__ 1 – requires use of equipment or device
Left: Normal__ Decreased__ 2 – requires help from another person for assistance, supervision or
f. Toe wiggle: Right: Normal__ Decreased__ teaching
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 3 – requires help from another person and equipment device 11. Any difficulties in maintaining activities
4 – dependent; does not participate in activity of daily living? No__ Yes__ Describe:
_____________________________________________
Feeding__; Bathing/hygiene__; Dressing/grooming__; Toileting__; 12. Any problems with concentration?
Ambulation__; Care of home__; Shopping__; Meal preparation__; No__ Yes__ Describe: ______
Laundry__; Transportation__ _____________________________________________________________

2. Oxygen use at home? No__ Yes__ Describe: ______________________ SLEEP REST PATTERN
3. How many pillows do you use to sleep on?_____
4. Do you frequently experience fatigue? No__ Yes__ Describe: _________ OBJECTIVE
___________________________________________________________
5. How many stairs can you climb without experiencing any difficulty (can be
individual number or number of flights)? ___________________________ SUBJECTIVE
6. How far can you walk without experiencing any difficulty? _____________ 1. Usual sleep habits: Hours per night ___; Naps: No__ Yes__ a.m.__
7. Has assistance at home for self-care and maintenance of home: p.m.__ Feel rested? Yes__ No__ Describe: ________________________
No__ Yes__ Who? __________ If no, would you like to have or believes 2. Any problems:
needs assistance: No__ Yes__ With what activities? _________________ a. Difficulty going to sleep? No__ Yes__
8. Occupation (if retired, former occupation): _________________________ b. Awakening during night? No__ Yes__
9. Describe you usual leisure time activities/hobbies: c. Early awakening? No__ Yes__
___________________ d. Insomnia? No__ Yes__ Describe: _____________________________
___________________________________________________________ 3. Methods used to promote sleep: Medication: No__ Yes__ Name: _______
10. Any complaints of weakness or lack of Warm fluids: No__ Yes__ What? __________________; Relaxation
energy? No__ Yes__ Describe: techniques: No__ Yes__ Describe:
___________________________________________________ _______________________________

COGNITIVE=PERCEPTUAL PATTERN
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 3. Knowledge level
OBJECTIVE a. Can define what current problems is: Yes__ No__
1. Review sensory and mental status completed in health perception-health b. Can restate current therapeutic regimen: Yes__ No__
management pattern
2. Any overt signs of pain? No__ Yes__ Describe: SELF-PERCEPTION AND SELF-CONCEPT PATTERN
_____________________
OBJECTIVE
SUBJECTIVE 1. During this assessment, does patient appear: Calm__ Anxious__
1. Pain Irritable__ Withdrawn__ Restless__
a. Location (have patient point to area) : __________________________ 2. Did any physiologic parameters change? Face reddened: No__ Yes__;
b. Intensity (have patient rank on scale of 0 to 10): __________________ Voice volume changed: No__ Yes__ Louder__ Softer__; Voice quality
c. Radiation: No__ Yes__ To where? changed: No__ Yes__ Quavering__ Hesitation__ Other: ______________
_____________________________ ___________________________________________________________
d. Timing (how often: related to any specific events): ________________ 3. Body language observed: ______________________________________
________________________________________________________ 4. is current admission going to result in a body structure or function change
_ for the patient? No__ Yes__ Unsure at this time__
e. Duration: _________________________________________________
f. What done relieve at home? SUBJECTIVE
__________________________________ 1. What is your major concern at the current time? ____________________
g. When did pain begin? _______________________________________ ___________________________________________________________
2. Do you think this admission will cause any lifestyle changes for you?
2. Decision-making No__ Yes__ What? ___________________________________________
a. Decision making is: Easy__ Moderately easy__ Moderately difficult__ 3. Do you think this admission will result in any body changes for you?
Difficult__ No__ Yes__ What? ___________________________________________
b. Inclined to make decisions: Rapidly__ Slowly__ Delay__ 4. My usual view of myself is: Positive__ Neutral__ Somewhat negative__

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5. Do you believe you will have any problems dealing with your current 2. Is patient married? Yes__ No__ Children? No__ Yes__ Ages of Children:
health situation? No__ Yes__ Describe: ___________________________ ___________________________________________________________
6. On a scale of 0 to 5 rank your perception of your level of control in this 3. How would you rate your parenting skills? Not applicable__ No difficulty__
situation: ___________________________________________________ Average__ Some difficulty__ Describe: ___________________________
___________________________________________________________ ___________________________________________________________
7. On a scale of 0 to 5 rank your usual assertiveness level: ______________ 4. Any losses (physical, psychologic, social) in past year? No__ Yes__
Describe: ___________________________________________________
ROLE-RELATIONSHIP PATTERN 5. How is patient handling this loss at this time? ______________________
___________________________________________________________
OBJECTIVE 6. Do you believe this admission will result in any type of loss? No__ Yes__
1. Speech Pattern Describe: ___________________________________________________
a. Is English the patient’s native language? Yes__ No__ Native language 7. Ask both patient and family: Do you think this admission will cause any
is: __________________ Interpreter needed? No__ Yes__ significant changes in the patient’s usual family role? No__ Yes__
b. During interview have you noted any speech problems? No__ Yes__ Describe: ___________________________________________________
Describe: ________________________________________________ 8. How would you rate your usual social activities? Very active__ Active__
Limited__ None__
2. Family Interaction 9. How would you rate your comfort in social situations? Comfortable__
a. During interview have you observed any dysfunctional family Uncomfortable__
interactions? No__ Yes__ Describe: ___________________________ 10. What activities or jobs do you like to do? Describe: ___________
b. If patient is a child, is there any physical or emotional evidence of ___________________________________________________________
physical or psychosocial abuse? No__ Yes__ Describe: ____________ 11. What activities or jobs do you dislike doing? Describe: _________
________________________________________________________ ___________________________________________________________
_
SEXUALITY-REPRODUCTIVE PATTERN
SUBJECTIVE
1. Does patient live alone? Yes__ No__ With whom? __________________ OBJECTIVE
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Review admission physical exam for results of pelvic and rectal exams. If 10. Have you talked to persons from the rape crisis center? Yes__
results not documented, nurse should perform exams. Check history to see if No__ If no, want you to contact them for her? Yes__ No__ If yes, was this
admission resulted from a rape. contact of assistance? No__ Yes__

SUBJECTIVE Male
Female 1. History of prostate problems? No__ Yes__ Describe: ________________
1. Date of LMP:___ Any pregnancies? Para__ Gravida__ Menopause? 2. History of penile discharge, bleeding, lesions: No__ Yes__
No__ Yes__ Year__ Describe: ___________________________________________________
2. Use of birth control measures? No__ N/A__ Yes__ Type: _____________ 3. Date of last prostate exam: _____________________________________
3. History of vaginal discharge, bleeding, lesions: No__ Yes__ Describe: 4. History of sexually transmitted diseases: No__ Yes__ Describe: ________
___________________________________________________________ ___________________________________________________________
4. Pap smear annually: Yes__ No__ Date of last pap smear: ____________
5. Date of last mammogram: Both
______________________________________ 1. Are you experiencing any problems in sexual functioning? No__ Yes__
6. History of sexually transmitted disease: No__ Yes__ Describe: _________ Describe:___________________________________________________
___________________________________________________________ 2. Are you satisfied with your sexual relationship? Yes__ No__
Describe:___________________________________________________
If admission is secondary to rape: 3. Do you believe this admission will have any impact on sexual functioning?
7. Is patient describing numerous physical symptoms? No__ Yes__ No__ Yes__ Describe: ________________________________________
Describe: ___________________________________________________
8. Is patient exhibiting numerous emotional symptoms? No__ Yes__ COPING-STRESS TOLERANCE PATTERN
Describe: ___________________________________________________
9. What has been your primary coping mechanism in handling this rape OBJECTIVE
episode? ___________________________________________________ 1. Observe behavior: Are there any overt signs of stress (crying, wringing of
hands, clenched fists, etc)? Describe: ____________________________

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SUBJECTIVE 1. Observe behavior. Is the patient exhibiting any signs of alterations in
1. Have you experienced any stressful or traumatic events in the past year in mood (anger, crying, withdrawal, etc.)? Describe: ___________________
addition to this admission? No__ Yes__ Describe:___________________ ___________________________________________________________
___________________________________________________________
2. How would you rate your usual handling of stress? Good__ Average__ SUBJECTIVE
Poor__ 1. Satisfied with the way your life has been developing? Yes__ No__
3. What is the primary way you deal with stress or problems? ____________ Comments: _________________________________________________
___________________________________________________________ 2. Will this admission interfere with your plans for the future? No__ Yes__
4. Have you or your family used any support or counseling groups in the How? ______________________________________________________
past year? No__ Yes__ Group name: 3. Religion: Protestant__ Catholic__ Jewish__ Muslim__ Buddhist__
________________________________ None__ Other:
Was the support group helpful? Yes__ No__ Additional comments: _____ _____________________________________________________
___________________________________________________________ 4. Will this admission interfere with your spiritual or religious practices? No__
5. What do you believe is the primary reason behind a need for this Yes__ How? ________________________________________________
admission? _________________________________________________ 5. Any religious restrictions to care (diet, blood transfusions)? No__ Yes__
6. How soon, after first noting the symptoms, did you seek health care Describe: ___________________________________________________
assistance? _________________________________________________ 6. Would you like to have your (pastor/priest/rabbi/hospital chaplain)
7. Are you satisfied with the care you have been receiving at home? No__ contacted to visit you? No__ Yes__ Who? _________________________
Yes __ Comments: ___________________________________________ 7. Have your religious beliefs helped you to deal with problems in the past?
8. Ask primary caregiver: What is your understanding of the care that will be No__ Yes__ How?____________________________________________
needed when the patient goes home? ____________________________
___________________________________________________________ GENERAL
1. Is there any information we need to have that I have not covered in this
VALUE-BELIEF PATTERN interview? No__ Yes__ Comments?
______________________________
OBJECTIVE
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2. Do you have any questions you need to ask me concerning your health,
plan of care or this agency? No__ Yes__ Questions: _________________
___________________________________________________________
3. What is the first problem you would like to have helped with?
____________
___________________________________________________________

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