Health Assessment Format

1. “Health Assessment Format”
1. Patient Profile:-
Name–
Age –
Sex –
Religion–
Marital Status–
Education –
Language–
Income/Month –
Date of Admission –
I.P. NO. –
Ward –
Address –
Diagnosis–
Date of surgery –
Date of care started –
Date of care ended –
Present Health Concern:
Chief Complaints –
Character, Onset, Location, Duration,
Severity, illness Assessment.
2. History of Present illness;-
Onset, Duration, Precipitating
event, reason for seeking help at present.
Past Medical and Surgical History;-

2. Previousillnessor
Diseases;
Childhood illness;
PreviousSurgery;
Allergies;
Accidents;
Immunization;
Family History;-
S.NO. Family
Members
Age Sex Occupation Health Status
FamilyTree:-
Personal History;-
Dietry Habits-
Sleep and Rest Pattern-
Elimination Pattern-
Habits-
Menstrual History;-
Age of Menarche-
Menstural Cycle-
Marital History;-

3. Age of Marriage;
Type of Marriage;
Socio-economic Background;-
Housing Pattern;
Ventilation;
Water Supply;
DrainageSystem;
ToiletFacility;
Monthly Income;
Other Facility;
“2nd Physical Examination:”
Name-
Sex-
Diagnosis-
Vital Signs;-
Temperature;
Pulse;
Respiration;
Blood Pressure;

4. Anthropometric Measurement:-
Height;
Weight;
Head to Foot Physical Assessment
General Appearance;
Body Built – Thin/Obese/Moderate.
Hygiene – Clean/Not Clean.
Health Status – Healthy/Unhealthy.
Posture – Straight/Bend/Unsteady.
Active - Active /Not Active.
Mental Status –
Alert,Anxious,Conscious,Oriented.
Skin:-
Colour – Normal/Cynosis/Jaundice/Pallor.
Turgor – Good/Poor Skin Turgor.
Temperature- Warm/Cold.
Nails:-
Colour- Pink/Cynosis/Pale.
Shape- Normal/Spoon Shaped Nails.

5. Deviations- Paronychio/Leukonychia.
Angle of Nails- Normal/Clubbing Angle.
Head and Face:-
Head
Size- Normal/Microcephay/Macrocephaly.
Shape- Symmetrical/Non-symmetrical.
Hair Colour- Black/Brown/Whitish.
Scalp-
Clean/Unclean/infected/dandruff/Pediculosis.
Face-
Normal/Pale/Flushed?Rashes/Puffiness/Cynosis.
Eyes;-
Eyebrow/Eyelashes/Eyelids- Normal/Abnormal.
EyeLids- Normal/Abnormal.
Conjuctiva- Pink/Pale.
Sclera- White/Yellow
Vision – Normal/Using Glass.
Ears;-
Shape –Normally Positioned/low slung ears.
Position- Normal/Abnormal.
Discharge- Absent/Present.

6. Hearing Acuity- Normal/Hearing loss.
Nose:-
Shape- Normal/Abnormal.
Crust/Discharge- Absent/Present.
Nasal Septal Deviation- Absent/Present.
Throat and Mouth;-
Lips- Pink/pale
Colour- Pink/pale
Gums-
Inflammation/Bleeding- Absent/Present.
Teeth; Normal/Tartar.
Alignment- Normal/Abnormal
Alignment/Missing Teeth.
Dental Caries- Present/Absent.
Tongue- Normal/Coated
Tongue/Fissures/Glossitis/Tongue tie.
Odour- Halitosis Absent/Present.
Tonsils- Normal/Enlarged Tonsils.
Neck;-
Thyroid Gland- Visible/Invisible.
Lymph Node- Palpable/Non Palpable.

7. Range of Motion- Normal/Abnormal
(Flexion/Extension)
Chest;-
Size- Normal/Abnormal.
Shape- Normal/Barrel Shape/Funnel
shape/Pigeon Shape.
Respiratory Rate- ………(in 1 minute)
Breath Sound- Regular/Irregular
Heart;-
Heart Rate-
Heart Sound- Normal/Abnormal.
Abdomen;-
Inspection;
Size- Normal/Abnormal.
Shape- Flat/Protruding/Concave Shape.
Scar- Absent/Present.
Peristalsis- Visible/Invisible.
Palpation;-
Tenderness- Non Tender/Tender of all
Quadrants.
Masses- Not Palpable/Palpable.

8. Percussion;-
Presence of gas/Fluid/Mass- Absent/Present.
Auscultation;-
Bowel Sounds- Active/Hypoactive/Hyperactive.
Extremities;-
Shape- Symmetrical/Non-Symmetrical.
Range of Motion- Possible/Not Possible.
Joint Mobility- Mobile/ Restricted Activity.
Back;-
Curvature Of Spine-
Normal/Scoliosis/Kyphosis/Kyphosis/Lordosis.
Genitalia and Rectum;-
Appearance- Normal/Swelling.
Discharge- Clear/Cloudy/Greenish coloured
Discharged.
Hemorrhoids- Absent/Present.
Prostate Gland- Normal/Enlarged.
3rd. Investigation;-
S.NO. Date Investigation Patient
Value
Normal
Values
Remarks

9. ................ ................ ................ ................ ................ ................
................ ................ ................ ................ ................ ................
4th Drug Profile;-
S.NO. Name
of yhe
Drug
Dosage Route Action Sideeffect Nurse’s
Responsibilities
.................................................
….. …… ….. …… ……. …………
……………………………………………
….. ……. …… ….. ……. ………..
………………………………………….
….. ……. ….. ….. ……. ………..
5th Nursing Diagnosis;-
1.
2.
3.
4.
5.
6th Nursing Care Plan;-
Assessm
ent
Nursin
g
Diagn
osis
Objectives/
Goals
Planni
ng
Ratio
nal
Implement
ation
Evaluat
ion
Subjective
Data
……. …………. ……. …… ……………. ………
Objective
Data
…….. …………. ……. ……. ………….. ………

10. 7th Health Education;-
If Surgical Patient.
Before The Investigation, Write Detail in surgical History
 Type of Anaesthesia.
 Type of Surgery.
 Date of Surgery.