Health Practitioner Physical Assessment Form PDF Details

A health practitioner physical assessment form, also known as a health questionnaire, is a document that helps practitioners assess the overall health of their patients. It can be used to track patient progress or to identify any potential problems. The form typically includes sections on medical history, family history, current health conditions, and medications. It may also include questions about lifestyle factors such as diet and exercise habits. By completing this form, patients provide practitioners with important information that can help them provide quality care.

These are some details about health practitioner physical assessment form. You might like to read it before typing in the form.

QuestionAnswer
Form NameHealth Practitioner Physical Assessment Form
Form Length5 pages
Fillable?Yes
Fillable fields264
Avg. time to fill out27 min 3 sec
Other nameshealth care practitioner form, health care practitioner assessment, nurse practitioner patient physical and yealth assessment form, form 4506 practitioner

Form Preview Example

1

Resident Name __________________________________

Date Completed ______________________

Date of Birth ____________________________________

 

Health Care Practitioner Physical Assessment Form

This form is to be completed by a primary physician, certified nurse practitioner, registered nurse, certified nurse- midwife or physician assistant. Questions noted with an asterisk are “triggers” for awake overnight staff.

Please note the following before filling out this form: Under Maryland regulations an assisted living program may not provide services to a resident who, at the time of initial admission, as established by the initial assessment, requires: (1) More than intermittent nursing care; (2) Treatment of stage three or stage four skin ulcers; (3) Ventilator services; (4) Skilled monitoring, testing, and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition; (5) Monitoring of a chronic medical condition that is not controllable through readily available medications and treatments; or (6) Treatment for a disease or condition that requires more than contact isolation. An exception to the conditions listed above is provided for residents who are under the care of a licensed general hospice program.

1.* Current Medical and Psychiatric History. Briefly describe recent changes in health or behavioral status, suicide attempts, hospitalizations, falls, etc., within the past 6 months.

2.* Briefly describe any past illnesses or chronic conditions (including hospitalizations), past suicide attempts, physical, functional, and psychological condition changes over the years.

3.Allergies. List any allergies or sensitivities to food, medications, or environmental factors, and if known, the nature of the problem (e.g., rash, anaphylactic reaction, GI symptom, etc.). Please enter medication allergies here and also in Item 12 for medication allergies.

4.Communicable Diseases. Is the resident free from communicable TB and any other active reportable airborne communicable disease(s)?

(Check one)

Yes

No If “No,” then indicate the communicable disease: ________________________

Which tests were done to verify the resident is free from active TB?

 

PPD

 

 

Date: __________

Result:___________mm

Chest X-Ray (if PPD positive or unable to administer a PPD)

Date: __________

Result_____________

Form 4506 Revised 9-15-09

2

Resident Name __________________________________

Date Completed ______________________

Date of Birth ____________________________________

 

5.History. Does the resident have a history or current problem related to abuse of prescription, non-prescription, over-the-counter (OTC), illegal drugs, alcohol, inhalants, etc.?

(a)Substance: OTC, non-prescription medication abuse or misuse

1.

Recent (within the last 6 months)

Yes

No

2.

History

Yes

No

(b)Abuse or misuse of prescription medication or herbal supplements

1.

Currently

Yes

No

2.

Recent (within the last 6 months)

Yes

No

(c)History of non-compliance with prescribed medication

1.

Currently

Yes

No

2.

Recent (within the last 6 months)

Yes

No

(d)Describe misuse or abuse: _________________________________________________________

____________________________________________________________________________________

6.* Risk factors for falls and injury. Identify any conditions about this resident that increase his/her risk of falling or

injury (check all that apply): orthostatic hypotension osteoporosis gait problem impaired

balance confusion Parkinsonism foot deformity pain assistive devices other (explain)

__________________________________________________________________________________________

 

7.* Skin condition(s). Identify any history of or current ulcers, rashes, or skin tears with any standing treatment

 

orders. _________________________________________________________________________________

 

__________________________________________________________________________________________

 

8.* Sensory impairments affecting functioning. (Check all that apply.)

 

 

 

 

 

 

 

(a) Hearing:

Left ear:

 

 

 

Adequate

 

Poor

Deaf

 

Uses corrective aid

 

 

 

(b) Vision:

Right ear:

 

 

 

Adequate

 

Poor

Deaf

 

Uses corrective aid

 

 

 

Adequate

Poor

 

Uses corrective lenses

Blind (check all that apply) -

R

L

(c) Temperature Sensitivity:

 

 

 

Normal

Decreased sensation to:

Heat

Cold

 

 

 

9. Current Nutritional Status.

Height

 

 

inches

 

 

Weight

 

lbs.

 

 

 

 

 

(a) Any weight change (gain or loss)

in the

past 6 months?

 

 

 

 

 

Yes

No

 

 

(b) How much weight change?

 

 

lbs. in the past

 

months (check one)

Gain

Loss

 

 

(c) Monitoring necessary? (Check one.)

 

 

 

 

 

 

 

Yes

No

 

 

If items (a), (b), or (c) are checked, explain how and at what frequency monitoring is to occur: ___________

 

__________________________________________________________________________________________

 

(d) Is there evidence of malnutrition or risk for undernutrition?

 

 

 

Yes

No

 

 

(e)* Is there evidence of dehydration or a risk for dehydration?

 

 

 

Yes

No

 

 

(f) Monitoring of nutrition or hydration status necessary?

 

 

 

 

 

Yes

No

 

 

If items (d) or (e) are checked, explain how and at what frequency monitoring is to occur: _______________

__________________________________________________________________________________________

(g)Does the resident have medical or dental conditions affecting: (Check all that apply)

Chewing Swallowing Eating Pocketing food Tube feeding

(h)Note any special therapeutic diet (e.g., sodium restricted, renal, calorie, or no concentrated sweets restricted): _________________________________________________________________________________

__________________________________________________________________________________________

(i)Modified consistency (e.g., pureed, mechanical soft, or thickened liquids): _________________________

__________________________________________________________________________________________

(j) Is there a need for assistive devices with eating (If yes, check all that apply):

Yes

No

Weighted spoon or built up fork

Plate guard

Special cup/glass

 

 

(k) Monitoring necessary? (Check one.)

 

 

Yes

No

If items (g), (h), or (i) are checked, please explain how and at what frequency monitoring is to occur:

__________________________________________________________________________________________

Form 4506 Revised 9-15-09

Alzheimer’s Disease Multi-infarct/Vascular Parkinson’s Disease
Date ______________ Score ______________

3

Resident Name __________________________________

Date Completed ______________________

Date of Birth ____________________________________

 

10.* Cognitive/Behavioral Status.

(a)* Is there evidence of dementia? (Check one.)

(b) Has the resident undergone an evaluation for dementia? (c)* Diagnosis (cause(s) of dementia):

(d)Mini-Mental Status Exam (if tested)

Yes

No

Yes

No

Other

10(e)* Instructions for the following items: For each item, circle the appropriate level of frequency or intensity, depending on the item. Use the “Comments” column to provide any relevant details.

Item 10(e)

A

B*

C*

 

D*

Comments

 

 

 

Cognition

 

 

 

I. Disorientation

Never

Occasional

Regular

 

Continuous

 

II. Impaired recall

Never

Occasional

Regular

 

Continuous

 

(recent/distant events)

 

 

 

 

 

 

 

 

III. Impaired judgment

Never

Occasional

Regular

 

Continuous

 

IV. Hallucinations

Never

Occasional

Regular

 

Continuous

 

 

 

 

 

 

 

 

V. Delusions

Never

Occasional

Regular

 

Continuous

 

 

 

 

Communication

 

 

 

VI. Receptive/expressive

Never

Occasional

Regular

 

Continuous

 

aphasia

 

 

 

 

 

 

 

 

 

 

Mood

and Emotions

 

 

VII. Anxiety

Never

Occasional

Regular

 

Continuous

 

 

 

 

 

 

 

 

VIII. Depression

Never

Occasional

Regular

 

Continuous

 

 

 

 

Behaviors

 

 

 

IX. Unsafe behaviors

Never

Occasional

Regular

 

Continuous

 

 

 

 

 

 

 

 

X. Dangerous to self or

Never

Occasional

Regular

 

Continuous

 

others

 

 

 

 

 

 

 

 

XI. Agitation (Describe

 

 

 

 

 

 

behaviors in comments

Never

Occasional

Regular

 

Continuous

 

section)

 

 

 

 

 

 

10(f) Health care decision-making capacity. Based on the preceding review of functional capabilities, physical and cognitive status, and limitations, indicate this resident’s highest level of ability to make health care decisions.

(a) Probably can make higher level decisions (such as whether to undergo or withdraw life-sustaining treatments that require understanding the nature, probable consequences, burdens, and risks of proposed treatment).

(b) Probably can make limited decisions that require simple understanding.

(c) Probably can express agreement with decisions proposed by someone else.

(d) Cannot effectively participate in any kind of health care decision-making.

11.* Ability to self-administer medications. Based on the preceding review of functional capabilities, physical and cognitive status, and limitations, rate this resident’s ability to take his/her own medications safely and appropriately.

(a) Independently without assistance

(b) Can do so with physical assistance, reminders, or supervision only

(c) Need to have medications administered by someone else

___________________________________

________________

Print Name

Date

______________________________________

 

Signature of Health Care Practitioner

 

Form 4506 Revised 9-15-09

4

Resident Name __________________________________

Date Completed ______________________

Date of Birth ____________________________________

 

PRESCRIBER’S MEDICATION AND TREATMENT ORDERS AND OTHER INFORMATION

Allergies (list all): ___________________________________________________________________________________________________________________

Note: Does resident require medications crushed or in liquid form? Indicate in 12(a) with medication order. If medication is not to be crushed please indicate.

12(a) Medication(s). Including PRN, OTC, herbal, & dietary supplements.

Include dosage route (p.o., etc.), frequency, duration (if limited).

12(b) All related diagnoses, problems, conditions.

Please include all diagnoses that are currently being treated by this medication.

12(c) Treatments (include frequency & any instructions about when to notify the physician).

Please link diagnosis, condition or problem as noted in prior sections.

12(d) Related testing or monitoring.

Include frequency & any instructions to notify physician.

Prescriber’s Signature ________________________________________________________

Date

______________________________

Office Address ______________________________________________________________

Phone

______________________________

Form 4506 Revised 9-15-09

5

Resident Name __________________________________

Date Completed ______________________

Date of Birth ____________________________________

 

PRESCRIBER’S MEDICATION AND TREATMENT ORDERS AND OTHER INFORMATION

Allergies (list all): ___________________________________________________________________________________________________________________

Note: Does resident require medications crushed or in liquid form? Indicate in 12(a) with medication order. If medication is not to be crushed please indicate.

12(a) Medication(s). Including PRN, OTC, herbal, & dietary supplements.

Include dosage route (p.o., etc.), frequency, duration (if limited).

12(b) All related diagnoses, problems, conditions.

Please include all diagnoses that are currently being treated by this medication.

12(c) Treatments (include frequency & any instructions about when to notify the physician).

Please link diagnosis, condition or problem as noted in prior sections.

12(d) Related testing or monitoring.

Include frequency & any instructions to notify physician.

Prescriber’s Signature ________________________________________________________

Date

______________________________

Office Address ______________________________________________________________

Phone

______________________________

Form 4506 Revised 9-15-09

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Step 1: Hit the orange button "Get Form Here" on this web page.

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Create the health care practitioner form PDF by typing in the data meant for each part.

writing health care practitioner assessment part 1

Type in the necessary information in the communicablediseases, Yes, and DateResultmm segment.

health care practitioner assessment communicablediseases, Yes, and DateResultmm fields to fill out

In the DateCompleted, RecentwithinthelastmonthsHistory, CurrentlyRecentwithinthelastmonths, CurrentlyRecentwithinthelastmonths, YesYes, NoNo, NoNo, NoNo, dDescribemisuseorabuse, confusion, orthostatichypotension, injurycheckallthatapplybalance, gaitproblemassistivedevices, footdeformity, and Parkinsonism segment, emphasize the essential details.

Filling in health care practitioner assessment part 3

The AdequateAdequate, PoorPoor, LeftearRightear, Cold, Heat, Poor, Normal, Adequate, NoLossNo, Weightlbs, YesGainYes, Usescorrectivelenses, Decreasedsensationto, Blindcheckallthatapply, and Specialcupglass area is the place where both sides can indicate their rights and responsibilities.

health care practitioner assessment AdequateAdequate, PoorPoor, LeftearRightear, Cold, Heat, Poor, Normal, Adequate, NoLossNo, Weightlbs, YesGainYes, Usescorrectivelenses, Decreasedsensationto, Blindcheckallthatapply, and Specialcupglass blanks to fill out

Prepare the document by looking at all these sections: Specialcupglass, Plateguard, Yes, and FormRevised.

Completing health care practitioner assessment step 5

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