Tobacco | # packs/day | Exposed to second hand smoking | # years used | | | |Alcohol
|Recreational Drug Use |Type | none |Frequency | n/a |
|IVDA |
| NIC |
|Social History |
Age | 2.5 |Sex | M |Marital Status | n/a | Language(s) spoken | English | |Major loss or change in past year
|Education | none | Occupation |n/a |
Appetite | Excellent | # of meals per day |4-5 | Prepared by | mother | Eats alone or with others |mother | |Food likes / dislikes
|Food Allergies | NKA | Reaction | n/a |
Religious Requirements | none | Recent Weight Gain / Loss | none | Dysphagia | N | |Bowel Habits (frequency, consistency of stool, use of laxatives)
|Urinary Elimination (frequency, dysuria, complaints) | 4-5 times a day; no complaints |
Usual #’s / Night |10 |Naps (time of day / length) |2 hours |Nocturia (Y / N) |N | |Use of Meds to Sleep
|Sleep Rituals | Likes to listen to a story before going to sleep |
|Hobbies | Drawing |
|Exercises | none |
|Bathing |
|Lives: |
Home Care / Hospice | |Adult Day Care | |Meals on Wheels | |Homemaker / Home Health Aid | | |Church Support Group
Intended Destination Post-discharge: |Home |Y |Undetermined | |Other | | |Post-discharge Transportation: |Car |Y |Ambulance | |Bus / Taxi | |Unable to Determine at this Time | | |Anticipated Financial Assistance Post-discharge? (Y / N)
Referrals: |Discharge Coordinator | |Home Health | |Social Service | |V.N.A. | | | |Other
|Comments | none |
|Primary Caregiver |Mother |Source of Information |Mother |
|Child’s Nickname | |School Grade (if applicable) |n/a |
|Fontanels |none |Head Circ. |WNL |
|Method of Feeding? |Self-feeding under parent |Feeds Self? (Y/N) | Y
