KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

NURSING ASSESSMENT FORM

Name: DOB: KCMHSAS ID #: Date:

Sex Weight Height Case Mgr
Pulse Resp B/P:
ALLERGIES
Recent Lab, X-Ray, Other Test Data:
Psychiatrist: Last Seen: Diagnosis
Physician 1: Last Seen: Diagnosis
Physician 2: Last Seen: Diagnosis
Physician 3: Last Seen: Diagnosis
Physician 4: Last Seen: Diagnosis
Optometrist: Last Seen: Diagnosis
Dentist: Last Seen:
Current Medications Dose/Frequency Prescribed by Purpose/Effectiveness per Client

Date of Last Tardive Dyskinesia Screen: (Complete and attach AIMS if appropriate)
SUBSTANCE ABUSE HISTORY
Caffeine Yes No Cigarettes (current) packs per day Years smoked
Alcohol (ever used) Yes No
Drugs & Narcotics Yes No By Prescription (sedatives, Minor Tranquilizers, opiates, stimulants,
(ever used) hallucinogens, inhalants, cannabis)
Type and frequency
Additional comments pertaining to
substance use: Include legal /vocational
problems, impact on life/social/family,
previous attempts to control:
(Patient’s response to “What major physical or medical
History of Physical Illness
problems, including surgeries have you had in your life?”)

(Patient’s response to “What major medical problems, like

Family History
heart trouble, strokes, or cancer, run in your family?”)

General Appearance
(Patient’s response to “Do any your medical problems make it
Health Affected ADL’s:
difficult for you to perform independent ADL’s?”)

55985775.doc
Effective Date: 01/16/07
Authorizer: Deputy Director of Access and Emergency Services
Application: KCMHSAS Staff and Contract Providers (MH)
Supercedes: 07/01
Page 1 of 7
 KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
NURSING ASSESSMENT FORM

Name: DOB: KCMHSAS ID #: Date:

Identification of Health and Safety Issues

REVIEW OF SYSTEMS
NEUROLOGICAL
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Frequent/Severe Headaches
Seizures
Dizziness
Impaired Balance/Coordination
Numbness/Tingling/Paresthesia
Paralysis
CVA (Stroke)
Tremor
Head Injury
Loss of Consciousness
Comments:
EENT
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Last Eye Examination
Impaired Vision: Comments:
Correction:
Cataracts
Glaucoma
Blurred Vision
Last Hearing Test
Impaired Hearing: Comments:
Ringing in Ears
Earache
Discharge from Ear Canal
Impaired Sense of Smell
Frequent Nose Bleeds
Frequent Colds/Sinus Infections
Needs Dental Work
Mouth/Gum Sores
Toothaches
Dentures
Comments:
Breath Odor Describe:
Difficult/Painful Chewing/Swallowing
Frequent Sore Throats
Hoarse Voice/Difficult Speaking
Thyroid Enlargement
Comments:
GASTROINTESTINAL
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Frequent Nausea
Frequent Vomiting
Indigestion/Heartburn
Ulcers
Diarrhea
Constipation
Odd Colored Stool
55985775.doc
Effective Date: 01/16/07
Authorizer: Deputy Director of Access and Emergency Services
Application: KCMHSAS Staff and Contract Providers (MH)
Supercedes: 07/01
Page 2 of 7
 KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
NURSING ASSESSMENT FORM

Name: DOB: KCMHSAS ID #: Date:

Use of Laxatives
Hemorrhoids
Diverticulitis
Comments:
RESPIRATORY
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Shortness of Breath
Wheezing/Congestion/Asthma
Productive Cough
Fatigue/Restricted ADL
COPD
Tuberculosis
Comments:
CARDIOVASCULAR
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Chest Pain
Edema
HI/LO BP: Medications?
Tracy/Brady – cardia
Irregular Pulse
Numb/Cold Hands/Feet (check digital pulses)
Congestive Heart Failure
Heart Attack
ADL Limitations
Comments:
HEMATOPOIETIC
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Anemia
Sickle Cell
Hemophilia (easy bruising/bleeding)
Comments:
GENITOURINARY
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Frequent Urination
Painful/Difficult Urination
Nocturia
Incontinence
Use of Diuretics
Cloudy/Bloody Urine
Flank Pain
Kidney Stones
Males Testicular Pain
Testicular Self Exam (freq.)
Prostrate Problems
Females Age of Menarche
LMP (date)
Regular Periods
Menopause (date)
Pregnant (EDC) (date)
# of Pregnancies
# of Live Births
# of Miscarriages
# of Abortions 55985775.doc
Effective Date: 01/16/07
Authorizer: Deputy Director of Access and Emergency Services
Application: KCMHSAS Staff and Contract Providers (MH)
Supercedes: 07/01
Page 3 of 7
 KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
NURSING ASSESSMENT FORM

Name: DOB: KCMHSAS ID #: Date:

Breast Lumps
Breast Self Exam (freq.)
Last OB/GYN Exam (date)
Vaginal/Penile Discharge
Itching in Genital Area
Sexually Active
If “yes”, Please see attached “Communicable Disease Risk Assessment”
Comments:
MUSCULOSKELTAL
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Pain/Stiffness
Weakness
Impaired ROM
Deformities
Prosthesis/Orthopedic Appliance
Fractures
Comments:
ENDOCRINE
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Diabetic
Hypoglycemia
Thyroid Dysfunction
Comments:
INTEGUMENTARY
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Flushed/Jaundiced Skin
Diaphoresis
Poor Skin Turgor
Comments:
SLEEP PATTERNS
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Average # hrs/night
Difficulty Falling Asleep
# Times Awake/night
Naps during Day
Comments:
IMMUNIZATIONS
TYPE LAST RECEIVED UNK CURRENT YES NO
DPT
TOPV
HIB
MMR
TD
TDS
Comments:
NUTRITIONAL PATTERNS
CONDITIONS/SYMPTOMS YES NO HISTORICAL UNK DATE
Usual # of Meals/daily
Recent Weight Change (>10 lbs.)
Recent change in appetite
Content with Current Weight
Special Diet Needed 55985775.doc
Effective Date: 01/16/07
Authorizer: Deputy Director of Access and Emergency Services
Application: KCMHSAS Staff and Contract Providers (MH)
Supercedes: 07/01
Page 4 of 7
 KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
NURSING ASSESSMENT FORM

Name: DOB: KCMHSAS ID #: Date:

Knowledge of 4 Basic Food Groups
Dietary Deficits
Appropriate Fluid Intake
Food Use as a Coping Mechanism
Eating Disorder
Comments:
SUMMARY/CLINICAL IMPRESSIONS:

SUMMARY OF CONSUMER HEALTH GOALS:

Overall Health seen as:
Strengths as related to Health:
Goals as related to Health:
(Treatment Recommendations are documented on the Person-Centered Annual Plan [Supported Needs page])

Date: Agency:
Prepared by (Signature) Name/Credentials

55985775.doc
Effective Date: 01/16/07
Authorizer: Deputy Director of Access and Emergency Services
Application: KCMHSAS Staff and Contract Providers (MH)
Supercedes: 07/01
Page 5 of 7
 KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
NURSING ASSESSMENT FORM

Name: DOB: KCMHSAS ID #: Date:

COMMUNICABLE DISEASE RISK ASSESSMENT

Please answer the following questions to determine if you may need further health screening.

The following questions are related to HIV (the virus that causes AIDS), Hepatitis, and Sexually Transmitted Diseases
(STD’s):

Have you engaged in unprotected sexual behaviors (oral, anal, or genital) with a partner whose health status is unknown
to you:

Yes No

Have you engaged in sexual behavior with individuals who have been identified as having any of the following?

HIV Yes No
Hepatitis Yes No
STD’s Yes No

Have you shared needles or injecting “works” with other individuals?

Yes No

Have you experienced other forms of blood-to-blood or body fluid contact (i.e. blood transfusions, hemophilia treatments,
and employment in the medical field), and have concerns regarding your HIV status:

Yes No

Please answer the following questions to determine if you may need health screening for TB:

Have you recently lived in a treatment facility, homeless shelter, drug house, jail, mental hospital, or in close quarters
with persons of unknown health status:

Yes No

Have you recently had close contact with someone diagnosed as having TB?

Yes No

Have you had a chronic cough for more than three weeks and any of the following symptoms?

Weight Loss Yes No

Fever for 3 days or longer Yes No
Night sweats Yes No
Coughing up Blood Yes No

55985775.doc
Effective Date: 01/16/07
Authorizer: Deputy Director of Access and Emergency Services
Application: KCMHSAS Staff and Contract Providers (MH)
Supercedes: 07/01
Page 6 of 7
 KALAMAZOO COMMUNITY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
NURSING ASSESSMENT FORM

Name: DOB: KCMHSAS ID #: Date:

I understand that I may be risk of contracting HIV, Hepatitis, STD’s, or TB if I answered “Yes” to any of the questions
above. I have been informed how HIV, Hepatitis, STD’s, or TB are transmitted; and ways to reduce the risk for
contracting these communicable diseases.

Consumer Signature Date

Completed by: (Signature/Credentials) Date

55985775.doc
Effective Date: 01/16/07
Authorizer: Deputy Director of Access and Emergency Services
Application: KCMHSAS Staff and Contract Providers (MH)
Supercedes: 07/01
Page 7 of 7