Client's General Appearance: Good Fair Poor Level of Care: Last Follow Up

Nurse

Vital Signs BP HR RR BG PsOx Weight

OBSERVATION / ASSESSMENT: (*) New problem (+) Continuous problem (±) Periodic problem

Allergies

10. DIET Diabetic Low Sodium Low Fat / Low Cholesterol Renal Regular Other

11. ACTIVITY LEVEL Independent Assistance needed: Total Moderate Minimum

12. MENTAL STATUS Alert Oriented Disoriented Forgetful Depressed Anxious Agitated Other

13. ANY CHANGES FROM PREVIOUS SV IN: -mental status? Yes No - functional status? Yes No - medical condition? Yes No - treatment regimen? Yes No - medication regimen? Yes No

14. Any recent falls? Yes No

15. Any recent hospitalizations or ER visits? Yes No

16. Any teachings / instructions provided? Yes No

17. Last Doctor's appointment? Date Reason:

18. Is client satisfied with provided services? Yes No

Comments: