SYSTEMS (continued) Ability to Understand Verbal Instructions?    No Yes Unknown Verbal Communications Comments: (Include specific known issues and lack of response during the assessment if pertinent). client’s Dental Issues:  Bleeding  Braces  Dental caries  Dentures Edema Edentulous Loose teeth Missing teeth     Pain Partial plate Retainer No known difficulties     Other  (specify) Last Dental Exam Date (month, day, year): (If Dental Comments: (Include duration, frequency and severity of dental issues). Integumentary Integumentary: (Complete Wound Assessment for all choices, including No Known Difficulty) Clammy Cold Cyanotic Diaphoretic     Dry Flushed Jaundice Pale     Warm No known difficulty Other    (specify) Integumentary Comments: (Include duration, frequency and severity of issues. Include current / past treatments if known). Skin Condition: Birthmarks Bruises Burns Decubitus     Lesions Piercings Rash Scars     Tattoos No known difficulty Other    (specify) Skin Condition Comments: (Include location and description) Podiatry Concerns: Blisters Bunions Calluses     Athlete’s foot Corns Ingrown toenails Spurs Warts     No known difficulty Other   (specify) Podiatry Comments: (Include location and description) (Include duration and severity. Include current / past treatments if known). 9
SYSTEMS (continued) Ability to Understand Verbal Instructions?  No  Yes  Unknown Verbal Communications Comments: (Include specific known issues and client’s lack of response during the assessment if pertinent). Dental Issues:  Bleeding  Edema  Pain  Other (specify)  Braces  Edentulous  Partial plate  Dental caries  Loose teeth  Retainer  Dentures  Missing teeth  No known difficulties Last Dental Exam Date (month, day, year): (If Dental Comments: (Include duration, frequency and severity of dental issues). Integumentary Integumentary: (Complete Wound Assessment for all choices, including No Known Difficulty)  Clammy  Dry  Warm  Cold  Flushed  No known difficulty  Cyanotic  Jaundice  Other (specify)  Diaphoretic  Pale Integumentary Comments: (Include duration, frequency and severity of issues. Include current / past treatments if known). Skin Condition:  Birthmarks  Lesions  Tattoos  Bruises  Piercings  No known difficulty  Burns  Rash  Other (specify)  Decubitus  Scars Skin Condition Comments: (Include location and description) Podiatry Concerns:  Athlete’s foot  Corns  No known difficulty  Blisters  Ingrown toenails  Other (specify)  Bunions  Spurs  Calluses  Warts Podiatry Comments: (Include location and description) (Include duration and severity. Include current / past treatments if known). 9
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