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Public Health Nursing Practice Manual

4 Nutritional Status Recent changes in weight: Hx of malabsorption: Problem with fluid intake:

Appetite:

poor/decreased

nausea

vomiting

no

yes

normal appetite

Current weight

______ pounds Normal weight

diarrhea problem with food intake:

Diet:

_______ pounds

no

yes

no

yes

no

yes

Date/ Initial

Food supply:

adequate

Adequate access to food:

Food Stamps:

no

yes

inadequate no (explain _____________________________________________

)

N/A

WIC:

no

yes

N/A

Breastfeeding:

yes

no

yes

N/A

Comments:

______________________________________________________________________________________

female

LMP

none

________________________________________________ interested N/A

5

Sexual History

male

Contraception used:

___________________________

_____________________

Taking contraceptive pills: Last pap test: (name): _______________________________________________ yes no N/A Last mammogram: ____________________________ Last prostate exam (PSA)/ result: ___________________ ____________________________________________________________________

History of STDs: Pregnant: OB/GYN Provider:

no no

yes (type / date of treatment):

yes

N/A

___________________________________________

If known, gestational age:

_______

weeks

EDD

______

Comments:

_____________________________________________________________________________________ ___________________________________________________________________________________________

6

Psychosocial

single Spouse/partner’s name: married domestic partner divorced separated Spouse/ partner living with client: widowed (year yes no _______________________________ Children (names and ages): ________________________________________________________________________

_____)

Children currently living with client:

no (all)

yes (all)

some (_______________________________)

Home:

house

apt.

How long at this residence

shelter

_________

homeless

hotel or SRO

trailer

ο other

_____________ I f l e s s t h a n 6 m t h s , p r e v i o u s r e s i d e n c _____________ e ________________________________

Household members:

  • #

    of adults

_____________

  • #

    of children

_____________

Source of income:

employment (type):

_____________________________________________

unemployed

with public benefits:

GR no

yes

CalWorks

SSI

other benefit: (specify _________________________ )Problem

__________________________________________________________

Health care coverage:

uninsured/self-pay private insurance

Medi-Cal

other government health plan

__________

__________________________________________________________

Problem with health care coverage: Financial support from family: Has primary care provider: Needs help with housing yes yes yes no no no yes no no Social support from family and friends: Family violence: potential yes yes no yes: Special needs of family: none ____________________________________________________________ _____________________________________________________________ Child care problems: yes no

Transportation: Can get to clinic appointments

no

yes

Transportation needs:

no

yes

_____________

Speaks English:

not at all

limited

fluent

Reads English:

not at all

limited

proficient

Writes English:

not at all

limited

proficient

Birthplace:

US

Other country__________________

writes

Date entered US

________________

reads

speaks

________________

primary language:

Clothing:

adequate

Education: highest grade completed

inadequate _______

____ Initial

______________________ Print Name/Title

_________________________ Signature/Title

____ Initial

______________________ Print Name/Title

_________________________ Signature/Title

© 2007 LAC DPH Public Health Nursing

E 15

Comments/ Date:

____

yes

Smokes cigarettes: Smokes cigars: Chews tobacco: Alcohol use:

Street drug use: Sexual activity: Safer sex practices:

no no no never never male female uses barrier protection yes _______ ppd x ________years yes _______ ppd x ________years yes _______ X qd x ______ years yes (amount/frequency) both never _______________ yes (type/duration of use) none rarely _____________ quit multiple partners: consistently ______ quit quit quit quit _____ _____ _____ ______ months/years ago no months/years ago months/ years ago months/years ago months/years ago yes # last 12 mos

7

Preventive Health Measures

mental health concerns:

no

Exercises at least 30 minutes 3 x/week:

yes

no

type of exercise

yes

Up-to-date immunizations:

no

____________________________________

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