client self assessment

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Section 1 My Name and Address Contains private and confidential Information. Date first written: Dates when updated:
Health History Current Diagnoses Intellectual Disability __________________ Mental Illness________________________ Physical Illness : Refer to OK Health Check_ Immunisations Name of Drug________________________ Date Given ________________________ Name of Drug________________________ Date Given ________________________ Name of Drug________________________ Date Given ________________________ Known Drug Allergies I am allergic to________________________ I am allergic to _______________________ Known Food /Product Allergies I am allergic to _______________________ I am allergic to _______________________ Refer to my current Medication Kardex
Page 1 and 2: Stick a photo of yourself here My N
Page 3: My height and weight: My date of bi
Page 7 and 8: Breathing Sleeping Maintaining Pers
Page 9 and 10: 2 Communication Name …………
Page 11 and 12: 4 Eating, Drinking & Nutrition Name
Page 13 and 14: 6 Elimination Name ……………
Page 15 and 16: 8 Leisure and Social Name ………
Page 17 and 18: 10 Pain Name …………………
Page 19 and 20: 12 Mood / Emotions Name ………
Page 21 and 22: 14 Self Concepts/ Independence Name
Page 23 and 24: 16 Expressing Sexuality Name ……
Page 25 and 26: 15 Motivation Name ……………

client self assessment

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