Adult Assessment Form Client’s first name …………………Middle/initial name….……..Family name………………….….…………..…… HN……………….…….DOB..…/….../……. Age…………..Gender ….……………...Marital status.………………………… Occupation………………..…….……………….……….. Level of education ………….…………..…………………….…….. Current address………………………………………………………………………….………………………………..……………………. Date of admission……………………..……….Date of data collection………………………..…………………………….. Admitted from: Home alone Home with relative Long-term care facility Mode of arrival: Wheel chair Stretcher Walk Source of information: Patient Relatives Chart Other (specify)…………………..……… Payment methods: Cash Insurance Government Universal coverage Post diagnosis ………………………………………………………………………………………………..………………….……….……… Operation (type, date) ……………………………………………………….……………………….…………….…….………………… Chief complaint (C.C.)…………………………………………………………………………………………………………………….…… Present illness (HPI) …………………………………………………………………………………………………………………………..… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….…………………
Past health history (PHx) (diseases, surgeries, accidents, previous hospitalization, date) ………………………………………………………………………………………………………………………………………….….………………… ……………………………………………………………………………………………………………………………….……………………….……… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….…………………
Family health history (FHx.) (genetic diseases, STD, communicable diseases) ……………………………………………………………………………………………………………………………………………..………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… Social history / lifestyle ……………………………………………………………………………………………………………………….. Allergies: Medication …………………………… Food……………………….. Others……………..……………
ชื่อผู้ใหญ่ประเมินฟอร์มของลูกค้า... ชื่อกลางอย่าง... นามสกุล... HN...วัน... …/….../……. อายุ... เพศ... สถานภาพ... อาชีพ... ระดับการศึกษา... ที่อยู่ปัจจุบัน... วันที่เข้า...วันรวบรวมข้อมูล... ยอมรับจาก: บ้านเดี่ยวบ้านกับญาติสิ่งอำนวยความสะดวกดูแลระยะยาววิธีการมาถึง: ล้อเก้าอี้เปลหามเดินแหล่งข้อมูล: ญาติผู้ป่วยแผนภูมิอื่น ๆ (ระบุ) ... วิธีการชำระเงิน: เงินสดรัฐบาลสากลประกันลงวินิจฉัย... การดำเนินงาน (ชนิด วัน) ... ร้องเรียนหัวหน้า (C.C.) …………………………………………………………………………………………………………………….…… Present illness (HPI) …………………………………………………………………………………………………………………………..… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… Past health history (PHx) (diseases, surgeries, accidents, previous hospitalization, date) ………………………………………………………………………………………………………………………………………….….………………… ……………………………………………………………………………………………………………………………….……………………….……… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… Family health history (FHx.) (genetic diseases, STD, communicable diseases) ……………………………………………………………………………………………………………………………………………..………………… …………………………………………………………………………………………………………………………………………….………………… …………………………………………………………………………………………………………………………………………….………………… Social history / lifestyle ……………………………………………………………………………………………………………………….. Allergies: Medication …………………………… Food……………………….. Others……………..……………
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