This nursing assessment document collects information about a patient's personal details, social situation, activities of daily living, health assessment, and identified health problems. It includes the patient's name, age, marital status, religion, languages spoken, education level, previous hospital experiences, associated illnesses, allergies, position in family, living situation, hygiene, sleep, diet, elimination patterns, mobility, vital signs, and priority health problems. The assessment comprehensively examines the patient's medical, social, and lifestyle factors.

1. NURSING ASSESSMENT
Name ofinstitution________________________________________________________
Date of assessment________________________________________________________
Name ofStudent Nurse_____________________________________________________
1. Patient’sPersonal Data
 Patient’sname______________________________________________
 Marital status_______________________________________________
 Age _________________________Sex___________________________
 Religion____________________________________________________
 Languagesspoken____________________________________________
 Educational level_____________________________________________
 Previoushospitalexperience:yes/No____________________________
If yes,brief description)________________________________________
___________________________________________________________
 Otherassociate illness:IHD/HTN/DM/TB/Others___________________
 Allergiesyes/no(specify)_______________________________________
2. SOCIAL DATA
i. Positioninthe family:_________________________________________
ii. No.Of children_______________________________________________
iii. Otherdependents:____________________________________________
iv. Housingfacilities:Slum/Kuccha/Pucca/Well built___________________
v. Livinglocality: urban/rural
vi. Toiletfacility: ownlatrine/publiclatrine/openfield
vii. Water supply: sufficient/insufficient
viii. Source of water:publicwatersystem(tap)/tubewell/well/river___________________
ix. Electricsupply:publicelectricsupplysystem/kerosene lamp/other_______________
3. ActivitiesOf Daily Living (ADL)
i. Personal Hygiene
 Bathingpattern:daily/alternate/notfix/lessfrequent
 Water preference:hot/cold/lukewarm
 Oral care:one time/twotimesaday
Uses fingercleaning/toothbrush/neemstick/powder/charcoal
ii. Sleepingpattern:soundsleep/disturbedsleep
iii. Habits:
 Smoke:yes/no
 Drinks:yes/ no ___if yes:habitual/social/occasional/addict
 Chews:yes/no___ if yes: specify_____________________________
 Anyotherhealthaffectinghabit______________________________

2. iv. Nutrition
 Likes/diskesof food_______________________________________
 On anydiettherapy:saltfree/diabetic/other__________________
 Foodpatternveg/non veg__________________________________
 Appetite good/moderate/ poor______________________________
v. Elimination
 Bowel pattern
 No of bowel movement/day_________________________
 Anyotherdifficulty( constipation/diarrhea)______________
 Urinary pattern
 Frequencyof micturation________times/day& ________ times/night
 Anyotherdifficulty( nocturia/dysuria,incontinence) _____________
vi. Reproductive ( forfemale patients)
 Menstruation:regular/irregular/dysmenorrhea
 If amenorrhea,LMP:______________________________________
4. Health Assessment
i. General appearance: Thin/Obese/normal
ii. Hair: groomed/infectedwithpediculosis/dandruff
iii. Level of consciousness:conscious/semi conscious/unconscious
iv. Behaviour:anxious/distressed/cheerful
v. Pain:yes/nospecify:____________________________________________
vi. Skin:normal/edematous/lossof skinturgor/rashes/jaundice/discoloration
vii. Vision:normal/Wearsglasses
viii. Hearing:normal/impaired/useshearingaids
ix. Oral inspection
 Mouth: normal/halitosis/sore throat/leukoplakia
 Teeth:normal(goodcondition)/decay/stained/looseteeth/dentures
 Tongue:moist/dryand coated/stained/other_________________
x. Mobility:ambulatory/difficultyinambulation/usescrutches/walkingaid
xi. Vital signs:
 Temperature:_____________________________
 Pulse:_________________/minute
 Respiration:____________/ minute
 B.P.:______________________
5. ProblemsIdentification( withpriorities)
i. ___________________________________________________________________________
ii. ___________________________________________________________________________
iii. ___________________________________________________________________________
iv. ___________________________________________________________________________
v. ___________________________________________________________________________