Teaching/Learning Assessment Tool

Subjective (Reports)
Communication: Dominant language (specify):____________________________ 
Second language:____________________________
Literate (reading/writing):_________________________________________________________________________
Education level:______________ Learning disabilities (specify):______________ 
Cognitive limitations:________________
Culture/ethnicity:______________ Where born:______________ 
If immigrant, how long in this country:__________________
Health and illness beliefs/practices/customs:________________________________________________________
Which family member makes healthcare decisions/is spokesperson for client:_____________________________
_____________________________________________________________________________________________
Presence of Advance Directives:_______ Code status:_______ Durable Medical Power of Attorney:_______ Designee:______
Health goals:__________________________________________________________________________________
Current health problem:____________________________ 
Client understanding of problem:________________________________
Special healthcare concerns (e.g., impact of religious/cultural practices, healthcare decisions, family involvement):_______
Familial risk factors (indicate relationship):_______ Diabetes:_______ Thyroid (specify):_______ Tuberculosis:_______ Heart disease:_______
Stroke:___________________________________ High BP:___________________________________
Epilepsy/seizures:_______ Kidney disease:_______ Cancer:_______ Mental illness/depression:_______ Other:_______

Prescribed medications (list each separately):
Drug:_____________________ Dose:_____________________ Times (circle last dose):_____________________
Take regularly:_____________________ Purpose:_____________________ Side effects/problems:_____________________

Nonprescription drugs/frequency:
OTC drugs:______________ Vitamins:______________ Herbals:______________ Street drugs:______________
Alcohol (amount/frequency):______________ Tobacco:______________ Smokeless tobacco:______________
Admitting diagnosis per provider:____________________________________________________________________________________
Reason for hospitalization/visit per client:___________________________________________________________
History of current problem/concern:________________________________________________________________
Client expectations of this hospitalization/visit:_______________________________________________________
Will admission cause any lifestyle changes (describe):________________________________________________
Previous illnesses and/or hospitalizations/surgeries:__________________________________________________
Evidence of failure to improve:____________________________________________________________________

Last complete physical examination:______________________________________________________________