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TITLE |
FIRST NAME |
SURNAME |
LOCATION SEEN AT |
ASSESSOR |
. |
|
|
|
|
ASSESSMENT DATE |
|
DATE OF BIRTH |
|
NAMED NURSE |
|
ADDRESS OF PATIENT |
|
TEL |
|
NEXT OF KIN |
|
RELATIONSHIP |
|
ADDRESS . |
|
TEL |
|
MEDICAL HISTORY |
DOCTOR |
|
TEL |
|
DIAGNOSIS |
|
COMMENTS |
|
MEDICATION |
|
ALLERGIC TO |
|
REASON FOR ADMISSION |
|
DSS LA AA |
|
alecRMATION GIVEN |
|
PAST OCCUPATION |
|
MOBILITY |
|
PERSONAL CARE |
|
MENTAL ALERTNESS |
|
ANXIETIES |
|
SMOKING |
|
DIET |
|
CONTINENCE |
|
RELIGION |
|
EQUIPMENT
WHEELCHAIR |
ZIMMER |
DENTURES TOP |
DENTURES BTM |
SPECTACLES |
HEARING AID |
. |
|
|
|
|
|
HOSPITAL HISTORY |
HOSPITAL |
|
TEL |
|
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