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Public Health Nursing Practice Manual

PHN ASSESSMENT FORM Date Form Initiated _________________ SPA _____ District ____________Program ______ CT___________ Client’s Last/First Name _____________________AKA Last/First Name________________________________

Telephone

____________________________________

Home

Work

Other

___________________

Address___________________________________________City____________________________Zip_______ Ethnicity/Race________________________________ Language ______________________________________

ACD

TB

______ LEAD

_______ SIDS

_____

Source of Referral: Referral Type

Disease Control

Health Line STD

______ ABUSE

Other

________________________

OB-HCF

OB-GENL

________

_________

OTHER

__________________

PHN ASSESSMENT Family Member

#_____ Declined _____________________ DOB_________________

Primary Care Health Coverage Primary Provider

No Yes Health Coverage

Family Violence No

Yes

Safety

Hazard

None

Immunization

Up-to-date

No

Healthy Habits

Healthy diet?

No

Exercises?

No

Yes

Yes NA

self Male Other

other _____ Female

Pregnant EDD

______

Diabetic

Asthma

No Yes Type _________ Needs Dental Care?

No Yes

Susp

Yes ________ ________ ________

Yes

Unsure ______

Smokes/Chem Dependency?

Safer Sex Practices?

No

No

Yes

Yes

NA

NA

Mental Health Concern

Declined

Declined

verified

Declined

Date _________________

________ Declined

by history Declined

#____ Declined _____________________ DOB______________

self Male Other

other _____ Female

Pregnant EDD ______ Diabetic Asthma Mental Health Concern

Date

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Primary Provider

No

No Yes Health Coverage

Yes

No Yes Type _________ Needs Dental Care?

Susp

No Yes Declined

Declined

Hazard

None

Yes ________ ________ ________ ________

Declined

Up-to-date

No

Yes

Unsure ______ verified by history Declined

Healthy diet?

Exercises?

No

Smokes/Chem. Dependency?

Safer Sex Practices? Declined

No

No

Yes

Yes

NA

No

Yes

NA

Yes

NA

#_____ Declined DOB________________

self Male Other

other _______ Female

Pregnant EDD ______ Diabetic Asthma Mental Health Concern Date _________________

#_____ Declined _____________________ DOB_________________

self Male Other

other _______ Female

Pregnant EDD ______ Diabetic Asthma Mental Health Concern Date _________________

Primary Provider

No Yes Health Coverage

No Yes Type _________ Needs Dental Care?

No

Yes

Declined

Primary Provider

No Yes Health Coverage

No Yes Type _________ Needs Dental Care?

No Declined

Yes

No

Yes

Susp

Declined

No

Yes

Susp

Declined

Hazard

Up-to-date

None

No

Hazard

Up-to-date

None

No

Yes

Yes

Yes ________ ________ ________ ________

Declined

Yes

Unsure ______ verified by history

Declined

________ ________ ________ ________

Declined

Unsure ______ verified by history Declined

Healthy diet?

Exercises?

No

No Yes

NA

Yes

Smokes/Chem. Dependency?

No

Yes

NA

Safer Sex

No

Yes

NA

Practices? Declined

Healthy diet?

No

Exercises?

No

Yes

NA

Yes

Smokes/Chem. Dependency?

No

Safer Sex Practices? Declined

No

Yes

Yes

NA

NA

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© 2007 LAC DPH Public Health Nursing

E4

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