Sample Proforma for Health Assessment of an Individual including Psychosocial Development

The sample proforma will provide you the guidelines to do comprehensive assessment of physical and psychosocial development of an individual.

1)Identification Data

Name : ..........................................................................................................

Age : ..........................................................................................................

Sex : ..........................................................................................................

Religion : ..........................................................................................................

Education : ..........................................................................................................

Occupation : ..........................................................................................................

Income : ..........................................................................................................

Marital Status : ..........................................................................................................

Address : ..........................................................................................................
..........................................................................................................

2)Physical Examination

Vital Signs: Temp..................... Pulse ..................... Resp ..................... B.P......................

Height..................... Weight .....................

Body built: Ectomorphic

Mesomorphic

Endomorphic

3)Head to Foot Assessment

Hair and Scalp ---- clean/dirty

shiny/dull/dry firm/brittle

Alopecia ---- yes/no

Pediculosis/dandruff/boils

Face : Pleasant/cheerful/serious/frowning/fearful/Moon face/

swollen face Skin colour: uniform/pigmented

Eyes : Appearance: Bright/sulk/clean/dirty

Conjunctiva: Pink/moist/dry/pale/discharge/Bitto’s spot

Cornea : glossy appearance/moist/dry/ulcer

Vision : normal/short/long sightedness

Ear : Clean /dirty/discharge/infection/boil/dizziness/pain/polyps/hearing/problem

Nose : clean/dirty/discharge/infection/boil/deviated septum /

epistaxisMouth : 1ips----pink/dry/moist/pale/cyanosed/cracks/angular stomatitis/cleft lip

Teeth : Clean/dirty/straight/malpositioned/white/yellow/stained/

cavities/decay/number

Gums : Pink/black/patches/clean/dirty

Tongue : Pink/pale/clean/moist/dry/coated

Throat and neck : Normal/congested

Lymph nodes : palpable/not palpable

Skin: colour: : pink/pale/pigmented/ clean/ dirty/ smooth/rough/ dry/ oily/elastic/ Non elastic

Nails : clean/dirty/brittle/pink/pale/cyanose/white patches/ spoon shaped nails

Feet : clean/dirty/cracked heels

Toe nails : short/long/clean

Respiratory system : rate/pattern/abnormal sounds/dyspnea/haemoptysis

Cardiovascular system: pulse: tachycardia/bradycardia/palpitation

GIT system: appetite : good/fair/poor/abdominal pain/indigestion /vomiting/Polydypsia/dyspepsia

Bowel habits : regular/constipation/diarrohea

Urinary System : normal/polyuria/oliguria/incontinent

Colour : straw/yellow

Muscular system : extremities: normal/any deformity/odema/pain

Bones and joints : normal/congenital anomalies/stiffness/swelling/limited movement/backache

Central Nervous System : oriented to time, place and person/confused/disoriented/nervousness/mood changes/memory loss

4)Habits

Sleep: 8-10 hrs/less than 8 hrs

Personal Hygiene: good/fair/poor

5)Sociological Health

Relationship with Family members/peers/significant others.............................

Relationship with neighbours: good/frequent fights

Occupational history: satisfaction with employment

Economic status perception of adequacy or inadequacy of income - Pattern of health

care: preventive/promotive/curative

6)Cognitive abilities

- - - - Intellect comprehension

- - - - Learning pattern

- - - - Memory

- - - - Concentration

- - - - Judgement

7)Spiritual Health

- - - - Faith in god: yes/no

- - - - Goes to temple/church: yes/no
 

- - - - Attitude towards health/disease: religious/neutral/fatalistic –

- - - - Respect towards other religions

8)Psychological Health

- - - - Behaviour

- - - - General appearance/facial expression

- - - - body posture

- - - - mannerisms

- - - - motor activity

- - - - Speech pattern

- - - - General mood and manner

- - - - Abnormal eating patterns

- - - - Memory

- - - - Orientation to time, play, person

- - - - Thought process

- - - - Thought context.