Scribd Logo
Upload

Welcome to Scribd!

  • 224 views

    Initial Patient Assessment in Opd

    Uploaded by

    Lokender Goyal
    This document contains an initial patient assessment form that collects information such as the patient's name, age, sex, date of birth, address, weight, height, BMI, allergies, presenting complaints, past medical history, family history, nutrition assessment, physical examination findings, immunization status, diagnosis, treatment plan, follow up instructions, and emergency contact information. The assessment covers multiple body systems and aims to gather a comprehensive overview of the patient's health status.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Initial Patient Assessment in Opd

    Uploaded by

    Lokender Goyal
    224 views4 pages
    This document contains an initial patient assessment form that collects information such as the patient's name, age, sex, date of birth, address, weight, height, BMI, allergies, presenting complaints, past medical history, family history, nutrition assessment, physical examination findings, immunization status, diagnosis, treatment plan, follow up instructions, and emergency contact information. The assessment covers multiple body systems and aims to gather a comprehensive overview of the patient's health status.

    Original Description:

    naaa

    Copyright

    © © All Rights Reserved

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document contains an initial patient assessment form that collects information such as the patient's name, age, sex, date of birth, address, weight, height, BMI, allergies, presenting complaints, past medical history, family history, nutrition assessment, physical examination findings, immunization status, diagnosis, treatment plan, follow up instructions, and emergency contact information. The assessment covers multiple body systems and aims to gather a comprehensive overview of the patient's health status.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    224 views4 pages

    Initial Patient Assessment in Opd

    Uploaded by

    Lokender Goyal
    This document contains an initial patient assessment form that collects information such as the patient's name, age, sex, date of birth, address, weight, height, BMI, allergies, presenting complaints, past medical history, family history, nutrition assessment, physical examination findings, immunization status, diagnosis, treatment plan, follow up instructions, and emergency contact information. The assessment covers multiple body systems and aims to gather a comprehensive overview of the patient's health status.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 4

    INITIAL PATIENT ASSESSMENT IN OPD

    Name : _________________ Age : Sex : Date :

    Date of Birth : ______/_____/_____ UHID No. : Address

    Weight : _____ KG Height : _____ CM BMI : Weight in kg/height in meter square

    ALLERGIES Provisional Diagnosis ……………………..

    PRESENTING COMPLAINTS

    RELEVANT PAST HISTORY :

    MILESTONES

    FAMILY HISTORY

    NUTRITIONAL ASSESSMENT & DIETARY HISTORY


    Calculate BMI Score Normal 0
    Under Weight <18.5 2 Less intake 1
    Normal 18.5-25 0 No intake of foods since past 5 days 2
    Over Weight 25-30 1 Acute illness 3
    Obese 30-39 2 HEALTH STATUS AS PER BMI
    Morbid Obesity >40 3 Healthy Underweight
    Overweight Obese

    PHYSICAL EXAMINATION/VITALS:

    Anaemia Cyanosis jaundice JVP clubbing Oedema feet


    Lymphadenopathy
    Temperature :
    Heart Rate :
    Blood Pressure :
    Respiratory Rate :
    SPO2 :
    Pain Assessment (Faces Scale) :

    SYSTEMIC EXAMINATION
    Ears :
    Nose :
    Throat :
    Eyes :

    CONDITION OF ORAL HEALTH :

    Teeth :
    a) Missing :
    b) Caries :
    c) Filled :

    Gums :
    Tongue :
    Overall Oral Hygiene :
    a) Good :
    b) Fair :
    c) Poor :
    d) V. Poor :

    SKIN

    RESPIRATORY SYSTEM :
    Chest Movements Symmetrical Asymmetrical
    Breath Sounds Vesicular Bronchial
    Adventitious sounds Crepts Ronchi
    Signs of Respiratory Distress
    Stridor
    Grunting
    Retractions

    CARDIOVASCULAR SYSTEM :
    Size, Position, Impulse of Heart :
    Heart Sounds S1 S2 Added sound Murmur :
    All Pulse :

    ABDOMEN :

    Consistency :
    Liver :
    Spleen :
    Any lump :
    Tenderness :

    CENTRAL NERVOUS SYSTEM:


    Consciousness :
    Neurological Deficit :
    Tendon reflexes :
    Planters :

    GENITOURINARY SYSTEM :
    Hydrocele : _______________________ Kidney :
    Varicocele : _______________________ h/o Calculi :
    Venereal disease : _______________________

    PREVIOUS INVESTIGATION/ NEW INVESTIGATION:

    FINAL DIAGNOSIS

    TREATMENT/PRESCRIPTION :

    DIET AS RECOMMENDED BY :

    Doctor :

    Dietician :

    Immunization Status
    Age Birth 6 weeks 10 weeks 14 weeks 16-18 months 4-5 Years
    BCG Birth
    O.P.V. Birth 1st 2nd 3rd Booster – 1 Booster - 2
    D.P.T. 1st 2nd 3rd Booster – 1 Booster - 2
    Hepatitis B Birth 1st 2nd 3rd Booster at
    6 months
    Hib 1st 2nd 3rd Booster
    Measles 1st dose booster
    MMR 9 month Booster at 4-6 years
    15 months
    JE 12 month Booster at
    13 months
    Influenza (IIV) 6 month 7 month Booster Every
    Year
    Typhoid 9-10 month Booster at
    Conjugate 2 years
    PCV 1st does 2nd 3rd Booster
    Rota Virus 1st does 2nd 3rd
    Varicella 15 month Booster
    Hepatitis A 12 month Booster
    Tdap/TD 10 years
    Td/TT 16 years
    HPV 9 year onward
    girls
    Meningococcal 9 month in
    Conjugate high risk group
    vaccine – 1

    FOLLOW UP

    DANGER SIGNS

    SIGNS OF LIFE THREATENING CONDITION

    In case of Emergency Contact :

    Doctor Signature with Name

    You might also like