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1-A AI – Important observations – Nursing
First Name
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Middle Name
Last Name
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Document ID
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1. Lost (more than 6 kg past 6 months)
*
Select
Yes
No
2. Poor walking, poor balance
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Select
Yes
No
3. Fatigue
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Select
Yes
No
4. Bleak
*
Select
Yes
No
5. Nervous / anxious
*
Select
Yes
No
6. Missing people around / loneliness
*
Select
Yes
No
7. Receives insufficient support from the environment
*
Select
Yes
No
Problems in the physical area
8. Wound infection
*
Select
Yes
No
9. (tendency to) constipation
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Select
Yes
No
10. Reduced appetite
*
Select
Yes
No
11. Anemia
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Select
Yes
No
12. Pain
*
Select
Yes
No
13. Immobility
*
Select
Yes
No
14. Reduced muscular strength & condition
*
Select
Yes
No
15. Uncontrolled diabetes
*
Select
Yes
No
Problems in the psychological field
16. Pale
*
Select
Yes
No
17. Sometimes anxious (fear of mobilization, fear of pain)
*
Select
Yes
No
18. Feels lonely
*
Select
Yes
No
Problems in the social field
19. Small social network / safety net
*
Select
Yes
No
20. Concerns about a demented wife
*
Select
Yes
No
Observations
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