STUDENT’S NAME / CLASS Mahmoud Fuqaha GRADE: Second Year University

INTERVIEW DATA: 29/9/2017 EVALUATOR: ____________________

CLIENT INITIALS: WARD: ICU BED NO: 4

SOURCE OF INFORMATION: Of the file and patient

AGE: 83 SEX: M_____F____ MARITAL STATUS: ____M____S_____W____D

DATE OF ADMISSION: D /M /Y EDUCATIONAL LEVEL: ____I____E____S_____U

ADMITTED FROM: ____HOME ______A&E_______CLINIC

MODE OF ARRIVAL: ___WHEEL CHAIR ____AMBULANCE ___WALKING ____STRETCHER

PRESENT MEDICAL DIAGNOSIS :( 0.5)

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REASON FOR HOSPITALIZATION (CHIEF COMPLAINING)

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PREVIOUS ILLNESS, COMPLAINTS AND /OR HOSPITALIZATION: (0.5)

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FAMILY HISTORY: (0.5)

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MEDICATION TAKEN AT HOME: (0.5)

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PRESENT SURGERY AND DATE: (0.5)

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SOCIAL STATES: (0.5)

NO.OF CHILDREN: ______________________

OCCUPATION: _________________________

ANY SUPPORT AT HOME: _________________

FINANCIAL IMPLICATION OF HOSPITALIZATION: ________________________________

SOCIOECONOMIC STATES: _______________________

GENERAL ASSESSMENT (1.5)

GENERAL APPEARANCE (SKIN COLOR, HIGHEST, WEIGHT)

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VITAL SING (V/S) TEMP, HR, RESP, BP

RANGE OF MOTION: ____________________________

BALANCE AND GAIT: ____________________________

HAND GRASPS: (WEAKNESS, PARALYSIS, STRONG)

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LEG MUSCLES: (WEAKNESS, PARALYSIS, STRONG)

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ACTIVITY DAILY LIVING (ADL): (EATING, TOILETING, BATHING AND AMBULATING)

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PAIN (0.5)

LOCATION: ___________________________

QUALITY: ____________________________

DURATION: ___________________________

INTENSITY: ___________________________

RADIATION: __________________________

PATHOPHYSIOLOGY (3)