Client Information Sheet NCM107
Client Information Sheet NCM107
Client Information Sheet NCM107
Be it known to all concerned that the information below will be treated with privacy and confidentiality.
CURRENT MEDICATION HISTORY (Please include current prescriptions and medications ONLY)
REACTION:
REACTION:
REACTION:
CIGARETTE SMOKER ALCOHOL USE CAFFEINE USE DOMESTIC ABUSE REGULAR EXERCISE MONTHLY BREAST EXAM
NEVER NO NOFORMER
NO NO YES
NO NOCURRENT-AMT/DAY
HAVE YOU HAD CHICKENPOX
NO YES YES YES YES
IF YES,
YES YES
AMT/WK IF YES, AMT/DAY
STREET DRUGS/MARIJUANA USE
NO
PREGNANCY
BREASTFEEDING
NEWBORN BELIEFS
This is to certify that the about information is true and AND onMISCONCEPTIONS
correct based the knowledge of my
client.
Client’s information shall be treated with privacy and confidentiality.
FOR LEARNING PURPOSES ONLY
STUDENT NURSE
SIGNATURE
JOSELITO O. FILLE, RN, MAN