Client Assessment Client Assessment Step 1 of 6 16% Patients DemographicsSelect Patient(Required)-- Select Patient --Adams, Kristal (DOB: 08/05/1952)Bond​, ​Latrice (DOB: 12/29/1968)Brown, Marqett (DOB: 12/03/1993)De Ceballos, Rosarios (DOB: 01/02/1949)Dulianto, ​Teobaldo (DOB: 11/27/1930)Dwana, Jones (DOB: 03/16/1975)eric, eric eric (DOB: 12/31/1970)Freeman​, Lenora (DOB: 10/07/1930)Garvy​, Sharon (DOB: 07/29/1961)Gilbert​, Rosa (DOB: 03/12/1928)Jordan, Larry (DOB: 02/07/0052)Kaifakhadi​, Abdulraheem (DOB: 11/15/1950)Kawaly​, Wilhemina (DOB: 12/23/1934)Mack​, Roberta (DOB: 03/07/1938)Mendez, Ana (DOB: 11/21/1948)Morton, Joseph (DOB: 02/24/1941)​​Norris, ​​Navi (DOB: 07/11/2000)Patrick​, ​Ladonna (DOB: 12/14/1980)Rodriguez, Jeremiah (DOB: 12/19/2007)Turner, Linda Hall (DOB: 08/22/1938)Willie, Dolores (DOB: 05/17/1946)Wilson, Mary (DOB: 05/15/1962)Wright, Trevon (DOB: 07/29/2004)Patient NamePatient Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code GenderFemaleMaleOtherDate of birth MM slash DD slash YYYY AgeMarital statusMarriedSingleWidowedDivorcedSeparatedPrimary LanguageAdmission dateVisitation Date MM slash DD slash YYYY Medical InformationPrimary care physicianPhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary diagnosisOther diagnosisDrug Allergies/SensitivitiesDiet/Nutrition Regular Low Salt Puree/Chopped Diabetic/No concentrated sweets Mental status Angry Depressed Uncooperative Hostile Panic Flat affect Mood swings Depressive feeling reported or observed None of the above Past Medical HistoryEnter medical recordDate MM slash DD slash YYYY Enter medical recordDate MM slash DD slash YYYY Enter medical recordDate MM slash DD slash YYYY Enter medical recordDate MM slash DD slash YYYY Past Surgical HistoryEnter medical recordDate MM slash DD slash YYYY Enter medical recordDate MM slash DD slash YYYY Enter medical recordDate MM slash DD slash YYYY Enter medical recordDate MM slash DD slash YYYY Financial InformationMedicaid # Insurance Private Pay Emergency ContactName First Middle Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneRelatiionshipGeneral HealthTemperatureRespirationBlood PressureCurrent weightDiet/Nutrition Regular Low salt Puree/Chopped Diabetic/No concentrated sweets Other Fluid Unlimited Restricted Fluid AmountIdentifying any changes over the past month Diagnosis Medications Health status Hospitalizations Falls Incidents Other Describe other changes Continuation of General Health Respiratory Within normal limits Cough Wheezing When is the person noticeably short of breath? Never short of breath Second Choice When walking less than 20 feet or climbing stairs With moderate exertion (e.g. dressing, using commode, walking)) With minimal exertion (eating, talking) At rest (during day/night) Pain/Discomfort - Frequency No pain or pain does not intefer with movement Less often daily Daily, but not constant All the time Please list sites of painSelect pain intensityHighMediumLow Person is experien, experiecing pain that is not easily releved. Occurs at least daily, and effects the ability to sleep, appetite, physical or emotional energy, concentration, personal relationships, emotions, or ability or desire to perform physical activity Cause of pain (if known)Pain treatmentGenitourinary status Catheter Urine Pain/Burning Distention/Retention Hesitancy Hematuria Person has been treated for a urinary tract infection over the past month Normal Discharge Other Enter other information CardiovascularRhythm Regular Irregular Cardiovascular - Blood Pressure BP and Pulse within normal limits RUE Non-Pitting Pitting LUE Non-Pitting Pitting LLE Non-Pitting Pitting RLE Non-Pitting Pitting Other Gastrointestinal StatusBowel MovementEnter frequency Diarrhea Constipation Nausea Vomiting Swallowing issue Pain Abdominal Epigastric Anorexia Other Bowel incontinence frequency Very rarely or never incontent of bowel Less than once per week Once to three times per week Four to six times per week On a daily basis More than once daily Patient has ostomy for bowel elimination Genitourinary StatusGenitourinary Status Catheter Content Urine Pain/Burning Distention/Retention Hesitancy Hermaturia Person has been treated for a urinary tract infection Normal Other If you checked other from above, enter details here NeurologicalCognitive functioning Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently Requires prompting (cueing, repetition, reminders)only under stressful or unfamiliar situations Requires assistance, direction in specific situatiort. requires low stimulus environment due to distractibility' Requires considerable assistance in routine situatcns. Is not alert and oriented or is unable to shift attention and recall r ore than half the time Totally dependent due to coma or delirium Speech Clear and understandable Slurred Garbled Aphasic Unable to speak Pupils Equal Unequal Movements Coordinated Uncoordinated ExtremitiesRight upperStrongWeakTremorsNo movementLeft upperStrongWeakTremorsNo movementRight lowerStrongWeakTremorsNo movementLeft lowerStrongWeakTremorsNo movementVision with corrective lenses if applicable NormaIvision in mostsituations; can see medication labels, newsprint Paltially impaired: can't see medication labels, but can see objects in path: cancount fingers at arms length Severely impaired; cannot locate objects without hearing or touching or person non-responsive Hearing with corrective device if applicabie Normalhearing in mostsituations. can hear normal conversational tone Paltially impaired: can't hear normal conversational tone Severely impaired: cannot hear even with an elevated tone PsychosocialBehaviors reported or observed Indecisiveness Diminished interestin mostactivities SIeep disturbances Reeentchange in appetite orweight Agitation A suicide attempt None ofthe above behaviors observed orreported Is this person receiving psychologicai counseling? Yes No MusculoskeletalMusculoskeletal Within Normal limits Unsteady Gait Poor endurance Altered Balance Weakness Deformity Contracture Impaired ROM Poor coordination Other Please enter details if you selected other Mental HealthSelect any of the listed behaviors Angry Depressed Uncooperative Hostile Panic Flat affect Anxious Phobia Agitated Paranoid Obsessive Compulsive Tic Spasms Mood Swings Drepressive Feeling reported or observed None of the above SkinColor Normal Pale Red Irritated Rash Is the skin intactYesNo Pressure Ulcer StagesStaze I: Redness of intact skin; warmth, edema, hardness, or discolored skin may be indicators01234 or moreSelect Number of Pressure UlcersStage 2: Partial thickness skin loss ofepidermis and/ordermis. The ulcer is superficiai and appears as an abrasion, blister, or shallow crater.01234 or moreSelect Number of Pressure UlcersStage 3: Full thickness skin loss; damage or necrosis ofsubcutaneous tissue; deep crater01234 or moreSelect Number of Pressure UlcersStage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone orsuppofting structures01234 or moreSelect Number of Pressure UlcersLocation of ulcers Legs Feet Lower back Buttocks Other Enter details if you selected otherPlease describe surgical or other types of wounds (describe location,size and nature of wound)