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Initial Patient Assessment in Opd

This document contains an initial patient assessment form that collects information such as the patient's name, age, sex, date of birth, address, weight, height, BMI, allergies, presenting complaints, past medical history, family history, nutrition assessment, physical examination findings, immunization status, diagnosis, treatment plan, follow up instructions, and emergency contact information. The assessment covers multiple body systems and aims to gather a comprehensive overview of the patient's health status.

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Lokender Goyal
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442 views

Initial Patient Assessment in Opd

This document contains an initial patient assessment form that collects information such as the patient's name, age, sex, date of birth, address, weight, height, BMI, allergies, presenting complaints, past medical history, family history, nutrition assessment, physical examination findings, immunization status, diagnosis, treatment plan, follow up instructions, and emergency contact information. The assessment covers multiple body systems and aims to gather a comprehensive overview of the patient's health status.

Uploaded by

Lokender Goyal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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INITIAL PATIENT ASSESSMENT IN OPD

Name : _________________ Age : Sex : Date :

Date of Birth : ______/_____/_____ UHID No. : Address

Weight : _____ KG Height : _____ CM BMI : Weight in kg/height in meter square

ALLERGIES Provisional Diagnosis ……………………..

PRESENTING COMPLAINTS

RELEVANT PAST HISTORY :

MILESTONES

FAMILY HISTORY

NUTRITIONAL ASSESSMENT & DIETARY HISTORY


Calculate BMI Score Normal 0
Under Weight <18.5 2 Less intake 1
Normal 18.5-25 0 No intake of foods since past 5 days 2
Over Weight 25-30 1 Acute illness 3
Obese 30-39 2 HEALTH STATUS AS PER BMI
Morbid Obesity >40 3 Healthy Underweight
Overweight Obese

PHYSICAL EXAMINATION/VITALS:

Anaemia Cyanosis jaundice JVP clubbing Oedema feet


Lymphadenopathy
Temperature :
Heart Rate :
Blood Pressure :
Respiratory Rate :
SPO2 :
Pain Assessment (Faces Scale) :

SYSTEMIC EXAMINATION
Ears :
Nose :
Throat :
Eyes :

CONDITION OF ORAL HEALTH :

Teeth :
a) Missing :
b) Caries :
c) Filled :

Gums :
Tongue :
Overall Oral Hygiene :
a) Good :
b) Fair :
c) Poor :
d) V. Poor :

SKIN

RESPIRATORY SYSTEM :
Chest Movements Symmetrical Asymmetrical
Breath Sounds Vesicular Bronchial
Adventitious sounds Crepts Ronchi
Signs of Respiratory Distress
Stridor
Grunting
Retractions

CARDIOVASCULAR SYSTEM :
Size, Position, Impulse of Heart :
Heart Sounds S1 S2 Added sound Murmur :
All Pulse :

ABDOMEN :

Consistency :
Liver :
Spleen :
Any lump :
Tenderness :

CENTRAL NERVOUS SYSTEM:


Consciousness :
Neurological Deficit :
Tendon reflexes :
Planters :

GENITOURINARY SYSTEM :
Hydrocele : _______________________ Kidney :
Varicocele : _______________________ h/o Calculi :
Venereal disease : _______________________

PREVIOUS INVESTIGATION/ NEW INVESTIGATION:

FINAL DIAGNOSIS

TREATMENT/PRESCRIPTION :

DIET AS RECOMMENDED BY :

Doctor :

Dietician :

Immunization Status
Age Birth 6 weeks 10 weeks 14 weeks 16-18 months 4-5 Years
BCG Birth
O.P.V. Birth 1st 2nd 3rd Booster – 1 Booster - 2
D.P.T. 1st 2nd 3rd Booster – 1 Booster - 2
Hepatitis B Birth 1st 2nd 3rd Booster at
6 months
Hib 1st 2nd 3rd Booster
Measles 1st dose booster
MMR 9 month Booster at 4-6 years
15 months
JE 12 month Booster at
13 months
Influenza (IIV) 6 month 7 month Booster Every
Year
Typhoid 9-10 month Booster at
Conjugate 2 years
PCV 1st does 2nd 3rd Booster
Rota Virus 1st does 2nd 3rd
Varicella 15 month Booster
Hepatitis A 12 month Booster
Tdap/TD 10 years
Td/TT 16 years
HPV 9 year onward
girls
Meningococcal 9 month in
Conjugate high risk group
vaccine – 1

FOLLOW UP

DANGER SIGNS

SIGNS OF LIFE THREATENING CONDITION

In case of Emergency Contact :

Doctor Signature with Name

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