BISHOP STATE COMMUNITY COLLEGE

DEPARTMENT OF NURSING
CLINICAL PREPARATION TOOL
STUDENT:_______________________________________DATE:_________________CLINICAL WEEK_______________________________
SOURCE(S) of objective date w/ reliability rating (1 weak - 4 strong)_____________________________________________________________
Weekly Objective(s):______________________________________________________________________________________________________
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CODE STATUS:_______________________________________
PATIENT HEALTH HISTORY
BIOGRAPHICAL DATA
Age/DOB:_______;_______/_______/________Sex:______Race:________Religion____________Marital Status_______# of Children________
Occupation:___________________Last Grade Completed:_________Language:_______________Usual Source of Healthcare:_____________
Reason for seeking healthcare:_____________________________________________________________________________________________
General appearance:______________________________________________________________________________________________________
HEALTH PERCEPTION/MANAGEMENT
Perception of health:______________________________________ Illness/Injuries__________________________________________________
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Concerns about health:____________________________________ Hospitalizations/Surgeries:________________________________________
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Measures to keep healthy:__________________________________ Drug/Tobacco/Alcohol Use:_______________________________________
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Chronological Story:______________________________________ Medication History (What do they take at home?):____________________
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Risk factors/Relevant History:______________________________ *Compliant w/ Meds @ home: Y N Explain;_________________________
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Disability Assessment:_____________________________________ Immunization Status:_____________________________________________
________________________________________________________ *INDICATES POTENTIAL KNOWLEDGE DEFICIT
PAST HISTORY
Childhood Illnesses (if applicable):___________________________
________________________________________________________ ALLERGIES;____________________________________________________
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