Nursing Assessment Form

June 11, 2011

When planning a patient’s care, nursing assessment forms come in handy in establishing the baseline data and the health condition of the patient. The nursing assessment form can be either in form of a questionnaire or a checklist. The assessment form is easy to understand and to fill. Here is a sample nursing assessment form.

Nursing Assessment Form

Patient name: _____________________________ Patient Number ______________

Care taker / Nurse name: ____________________________ Phone _________________

ASSISTIVE DEVICES (indicate YES to all devices that apply)

Hearing aid(s) ___________ Glasses ___________ Contacts ___________

Crutches ___________ Walker ___________ Cane  ___________

Wheelchair ___________ others (specify) ________________________________


Primary Language: _____________________  Interpreter required? _____________

Whom do you live with? _________________________________

Any family members (or others) that information should be shared with? (List names)

____________________ _________________________________
____________________  _________________________________

Is there family member willing and able to assist with healthcare, at home? _____________

Have you had sleeping problems? ____________________

Would you like assistance with or information regarding: (indicate all that apply)

Complementary therapies and cancer support group’s ___________________

Financial support and family counseling concerns ______________________

Nutrition supplies and medical equipment issues _______________________

Household help, meal preparation or spiritual support ___________________

Workplace issues and transportation concerns _________________________

Referral Made ____________________to ______________________

Assessment Mode: _________________By:______________________

Signature: ___________________Date: ______________________


Download Nursing Assessment Form In Word Format

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