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Name: __________________________



Patient Identification

Date of Admission: ____/____/____ Time of Admission: ____:____ am / pm Transported By: _____________________ Accompanied By: ___________________________ Age: ____ Sex: Male Female Vital Signs: B/P ____/____, T ______, P ______ (Regular / Irregular), R ______ Diagnosis: _____________________________________________________________________ Reason for Admission: Rehab Wound Care IV Tube Feeding Respiratory Dialysis TB Status: CXR Date: ____/____/____ (Neg / Pos) or Physician Statement of No TB Medications: ALLERGIES: NKDA / NKFA See Admission/Transfer Orders Medication/Food Medication/Food _____________________________________ _____________________________________ _____________________________________ _____________________________________ CARDIOVASCULAR Chest: Symmetrical Asymmetrical Heart: Regular Irregular Tachy Brady Murmur Rub Gallop Pacemaker Pulses: Radial: Present, L R / Absent, L R Pedal: Present, L R / Absent, L R Edema: None or _______________________ RESPIRATORY Dyspnea Tachypnea S.O.B. Cough: None Dry Productive Sputum: Scant Moderate Copious Oxygen Vent Trach CLEAR Right Left DIMINISHED Right Left COURSE Right Left WHEEZES Right Left NEUROLOGIC Unable to Assess/Unresponsive Pupil Reaction: PERRL Other: ___________ Grips: R/L Equal L>R R>L Push/Pull: R/L Equal L>R R>L Dizziness Syncope Seizures SENSORY Numbness Tingling Site: ______________ Weakness Site: _______________________ Vision Hearing Adequate L R Adequate L R w/Glasses L R w/Aids L R Poor L R Poor L R Blind L R Deaf L R Paralysis/Paresis Site: _________________ Contractures Site: _____________________ Prosthesis Specify: ____________________ Weight Bearing Status: As Tolerated (WBAT) TTWB or NWB Site: __________________ Other: ________________________________



GASTROINTESTINAL Soft Round Flat Non-Tender Tender Distended Acsites Bowel Sounds: Active x 4 Quadrants Hypoactive Hyperactive Absent Site: RUQ RLQ LUQ LLQ Nausea/Vomiting COGNITIVE/COMMUNICATION Alert & Oriented x4 Comatose Intermittent Confusion Disoriented Speech: Clear Garbled/Mumbles Aphasia Communication Board Gestures/Sounds Language: English Spanish Other: ____________________ Comprehension: Slow Quick Unable Indep. Assist Dep. Ambulation Transfer Dressing Toileting Bathing



Walker W/C Cane Geri-chair for positioning Splint/ Brace, Site: ______________ Peripheral IV, Site: ___________ PICC Line, Site: ___________ Central Line, L / R J or G Tube NG Tube Surgical Drain, Site: ____________ PICC/CL Length: _______cm Dialysis Port/Shunt, Site: _________________ Other: _______________________________ BOWEL BLADDER Continent Incontinent Last BM: __/__/__ Continent Incontinent Colostomy Ileostomy Rectal Bag Foley Catheter Suprapubic Catheter BM every 3 days Constipation Diarrhea Nephrostomy, L / R ORAL Own Teeth Broken, Loose or Carious Condition: Good Fair Poor Dentures, Upper Lower Do Dentures Fit?: Yes / No Pain on admit? No / YesRate 0-10: ____ NUTRITION Dysphagia Tube Feeding Thick Liquids Mechanically Altered Diet Recent Weight Loss Recent Weight Gain IV Fluids Chronic Acute Frequency: No Pain Less than daily Daily but not constant Constant Location: ______________________________ Intensity: No Pain Mild Distressing Severe Horrible Excruciating What makes pain worse? Movement Other: ________________________________ What makes pain better? Medication Rest Positioning Other: _____________________


Non-verbal: Observe for evidence of pain. Grimacing Clenching Guarding Diaphoresis Elevated Heart Rate Furrowed Brow

Using the diagram below, indicate all body marks, such as old/recent scars/incisions, bruises, skin tears, discolorations, suspicious areas, abrasions, pressure/vascular/diabetic ulcers. Record measurements on the appropriate form depending on the type of skin condition.

Incision: _____________________ Scar: ________________________ Bruise: ______________________ Skin Tear: ____________________ Discoloration: _________________ Abrasion: ____________________ Suspicious Area: _______________ Pressure Ulcer: ________________ Vascular/Stasis Ulcer: __________ Diabetic Ulcer: ________________ Other: _______________________ General Skin Condition: Pale Pink Warm Cold Dry Diaphoretic Jaundice Ashen Cyanotic ORIENTATION TO FACILITY Unable to Orient Reason: __________________ Facility Activities Staff Bathroom Call Light Telephone Lighting Visiting Hours Meal Times Smoking Rules/Location MOOD/BEHAVIOR Alert Angry Fearful Noisy Friendly Questioning Cooperative Lethargic Anxious Depressed Quiet Passive Secure Talkative Tearful Combative HABITS Uses Tobacco: Yes / No Uses Alcohol: Yes / No Sleep Pattern: Usual Bed Time: ____:____ Usual Arising Time: ____:____ Naps: Yes / No PSYCHOSOCIAL Family Visiting/Closest with: _________________________ Involved in Plan of Care: Yes / No Motivation Toward Rehab: Good Fair Poor



Completed By: Signature: _____________________________ Title: _________________ Date: ____/____/____