ent department
Patient Assesment
Muhammad Ali
12065354
Male 45
Saudi
07
January
2021
Please Note :
If the answer is positive make tick
If the answer is negative leave it blank
If the answer is not accepted
Temp.:
Nurse ID & Sign : Noor Muhammad
Pulse: BP: O2 Sat: Weight:

I. Histoy

1.C/O / History of Present Illness
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2.Past Medical & Surgical History
3. Family History ( including: Social / psychological factors)
4. Allergies:

Adverse Drug Reaction :

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Drug History :

MEDICATIONS :

Risk Of Fall :

II. Examination

a. General
b. Systems Review
Titel 01 Titel 01 Negative Positive Comment
A HEAD & NECK
B CNS
C CVS
D RESP
E GIT
F GENITO-URINARY
G SKIN
H ENDOCRINE
I Others: Please Specify

Please elaborate more if any System Review is Positive:

3. Local
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a. EARS
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02     Point 02
03     Point 03
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b. NOSE & SINUSES
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02     Point 02
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c. THROAT & LARYNX
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02     Point 02
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d. HEAD & NECK
01     Point 01
02     Point 02
03     Point 03

III. SPECIAL NEEDS

Functional Screening Criteria :
Nutritional Screening Criteria :
Psychological Screening Criteria :
Psychological Screening Criteria :
Spiritual / Cultural Screening :

* Choose any of the following options based on the above-mentioned criteria :

Screening Category Positive Screening Doctor will
handle
(Tick if YES)
Referred for
further assessment
(Tick if YES)
Patient refused
referrals
(Tick if YES)
Functional Screening Icon Icon
Nutritional Screening Icon Icon
Psychological Screening Icon Icon Icon
Socio-economic Screening Icon Icon
Spiritual / Cultural Screening Icon Icon
Spiritual / Cultural Screening :
Pain Assessment :
Pain Score image
Patient’s pain relief goal :

# Need for Additional Specialized Assessment:

IV. INVESTIGATIONS

V. DIAGNOSIS

VI. MANAGEMENT PLAN

VII. PRESCRIBED MEDICATIONS

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Physician’s Name : Dr. Khaled Al JAber

ID #: 12065354

Date : 07-01-2020

Age : 10:35 AM

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