ADMISSION ASSESSMENT

DEMOGRAPHIC DATA Date: ______________ Time: HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Name:
Address: OBJECTIVE
Age: 1. Mental Status (indicate assessment with a )
B.place: a. Oriented__ Disoriented__
Gender: Time: Yes__ No__; Place: Yes__ No__; Person: Yes__ No__;
Civil Status: b. Sensorium
Religion Alert__ Drowsy__ Lethargic__ Stuporous__ Comatose__
Highest Educational Attainment: Cooperative__ Combative__ Delusional__
Occupation: c. Memory
Monthly budget Recent: Yes__ No__; Remote: Yes__ No__

VITAL SIGNS:
Temperature: ____F ____C ; oral__ rectal __ axillary __ tympanic __
Pulse Rate: ____bpm; radial __ apical ___; regular ___ irregular __ 2. Vision
Respiratory Rate: ___cpm; abdominal ___ diaphragmatic ___ a. Visual acuity: Both eyes 20/___; Right 20/___; Left 20/___; Not
Blood Pressure: left arm ___ right arm___; assessed___
standing__ sitting__ lying down ___ b. Pupil size: Right: Normal__ Abnormal__;
Weight: __ pounds; ___kg Left: Normal__ Abnormal__
Height: ___feet ___inches; ___meters c. Pupil reaction: Right: Normal__ Abnormal__;
Left: Normal__ Abnormal__

A. Anthropometric Data (only those applicable) 3. Hearing

Height = __ cm (for both adult & pedia BMI = __ (for adult) a. Not assessed__
Weight = __ Kg (for both adult & pedia IBW = __ (for adult & pedia) b. Right ear: WNL__ Impaired__ Deaf__; Left ear: WNL__ Impaired__
Head Circumference = __ cm (for pedia) Deaf__
Chest Circumference = __ cm (for pedia) c. Hearing aid: Yes__ No__
Abdominal Circumference = __ cm (for pedia0
4. Taste
a. Sweet: Normal__ Abnormal__
Do you have any allergies? No__ Yes__ What?! ________________ b. Sour: Normal__ Abnormal__ Describe:_______________________
c. Tongue movement: Normal__ Abnormal__
Good day, Ms Jessalyn , your nurse for today, thru this platform, magkakaroon d. Tongue appearance: Normal__ Abnormal__
lang po tayo ng series of comprehensive assessments. I hope hindi po kayo 5. Touch
makaramdam ng upset sa akin dahil sa mga questions na itatanong ko po. Would a. Blunt: Normal__ Abnormal__
that be okay with you? b. Sharp: Normal__ Abnormal__
c. Light touch sensation: Normal__ Abnormal__
So how are you feeling today? d. Proprioception: Normal__ Abnormal__
So nabanggit ko po kanina yung name ko, naaalala niyo pa po ba yung name ko? e. Heat: Normal__ Abnormal__
How old are you? f. Cold: Normal__ Abnormal__
Do you know kung nasan po kayo ngayon? g. Any numbness? No__ Yes__
Alam niyo po ba pumunta ditto sa ating clinic mual sa inyong bahay? Maari mo h. Any tingling? No__ Yes__
bang sabihin sa akin and direksyon?
What is the day today, Ma’am? And the month? 6. Smell
a. Right nostril: Normal__ Abnormal__
Okay, good. Now po magsasabi po ako sa inyo ng 3 words and then I will ask you b. Left nostril: Normal__ Abnormal__
po later kung natatandana niyo pa po.
7. Cranial Nerves: Normal__ Abnormal__
Reason for Seeking Health Care
8. Cerebellar Exam (Romberg, balance, gait, coordination, etc.)
Past Medical History Normal__ Abnormal__
-Childhood:
9. Reflexes: Normal__ Abnormal__ Describe: _

-Injuries: 10. Any enlarged lymph nodes in the neck? No__ Yes__ Location and size:
-Hospitalization: 11. General appearance:
a. Hair:
-Operation: b. Skin:
-Allergies: c. Nails:
-Medication: d. Body odor:

-Immunization SUBJECTIVE
-Last Examination 1. How would you describe your usual health status?
Good__ Fair__ Poor__
Obstetric Gyne 2. Are you satisfied with your usual health status?
-LMP: Yes__ No__ Source of dissatisfaction:
-Menarche: 3. Tobacco use? No__ Yes__ Number of packs per day? Aware of the effects? __
-Menstruation: 4. Alcohol use? No__ Yes__ How much and what kind? Aware of the effect? ____
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5. Street drug use? No__ Yes__ What and how much? b. Eyes
6. Any history of chronic disease? No__ Yes__ Describe: i. Moist__ Dry__
7. Immunization history: Tetanus__ Pneumonia__ Influenza__ MMR__ Polio__ ii. Color of conjunctiva: Pale__ Pink__ Jaundiced__
Hepatitis B__ iii. Lesions: No__ Yes__
8. Have you sough any health care assistance in the past year? No__ Yes__ If
yes, why? 3. Edema
9. Are you currently working? No__ Yes__ How would you rate your working a. General: No__ Yes__
conditions? (e.g. safety, noise, space, heating, cooling, water, ventilation)? Abdominal girth: ___inches
Excellent__ Good__ Fair__ Poor__ Describe any problem areas:_ b. Periorbital: No__ Yes__
10. How would you rate living conditions at home? Excellent__ Good__ Fair__ c. Dependent: No__ Yes__
Poor__ Describe any problem areas: Ankle girth: Right:__ inches; Left__inches
11. Do you have any difficulty securing any of the following services?
4. Thyroid: Normal__ Abnormal__ Describe:
Grocery store: Yes:__ No:__; Pharmacy: Yes__ No__; Health Care Facility: 5. Jugular vein distention: No__ Yes__
Yes:__ No:__; Transporation: Yes:__ No:__; Telephone (for police, fire, 6. Gag reflex: Present__ Absent__
ambulance): Yes:__ No:__; If any difficulties, note referral here: 7. Can patient move easily (turning, walking)? Yes__ No__
8. Upon admission, was patient dressed appropriately for the weather?
12. Medications (over-the-counter and prescription) Yes__ No__ Describe:

Name Dosage Times/Day Reason Taken as Ordered For breastfeeding mothers only:
Yes__ No__
9. Breast exam: Normal__ Abnormal__
10. If mother is breastfeeding, have infant weighed. Is infant’s weight within
13. Have you followed the routine prescribed for you? normal limits? Yes__ No__
Yes__ No__ Why not?
14. Did you think this prescribed routine was best for you? SUBJECTIVE:
Yes__ No__ What would be better? 1. Any weight gain in the last 6 months? No__ Yes__ Amount:
15. Have you had any accidents/injuries/falls in the past year? 2. Any weight loss in the last 6 months? No__ Yes__ Amount:____________
No__ Yes__ Describe: 3. How would you describe your appetite? Good__ Fair__ Poor__
16. Have you had any problems with cuts healing? 4. Do you have any food intolerance? No__ Yes__ Describe:
No__ Yes__ Describe: 5. Do you have any dietary restrictions? (Check for those that are a part of a
17. Do you exercise on a regular basis? prescribed regimen as well as those that patient restricts voluntarily, for
No__ Yes__ Type & Frequency: example, to prevent flatus) No__ Yes__ Describe:
18. Describe the place you are currently living in______________ 6. Describe an average day’s food intake for you (meals and snacks):
19. Does he/she have any pets? If so, what kind? 7. Describe an average day’s fluid intake for you.
20. What does the person do to improve or maintain his/her health?__________ 8. Food preparation ______
21. Have you experienced any ringing in the ears: Right ear: Yes__ No___ Left 9. Describe food likes and dislikes.
ear: Yes__ No__ 10. Would you like to: Gain weight?__ Lose weight?__ Niether__
22. Have you experienced any vertigo: Yes__ No__ How often and when? 11. Any problems with:
23. Do you regularly use seat belts? Yes__ No__ a. Nausea: No__ Yes__ Describe:
24. For infants and children: Are car seats used regularly? Yes__ No__ b. Vomiting: No__ Yes__ Describe:
25. Do you have any suggestions or requests for improving your health? c. Swallowing: No__ Yes__ Describe:
Yes__ No__ Describe: d. Chewing: No__ Yes__ Describe:
26. What are THE PRACTICED traditional concepts of health and illness?Beliefs e. Indigestion: No__ Yes__ Describe:
and practices? ___________________________ 12. Would you describe your usual lifestyle as: Active__ Sedate__
27. Do you do (breast/testicular) self-examination? No__ Yes__
For breastfeeding mothers only:
13. Do you have any concerns about breast feeding? No__ Yes__ Describe:
NUTRITIONAL-METABOLIC PATTERN ___________________________________________________
14. Are you having any problems with breastfeeding? No__ Yes__ Describe:
OBJECTIVE MEALS Date & Day Date & Day Date & Day
1. Skin examination
a. Warm__ Cool__ Moist__ Dry__ Breakfast
b. Lesions: No__ Yes__ Describe: (time)
c. Rash: No__ Yes__ Describe: Snacks (if - amount per - amount per - amount per serving
d. Turgor: Firm__ Supple__ Dehydrated__ Fragile__ any) serving serving
e. Color: Pale__ Pink__ Dusky__ Cyanotic__ Jaundiced__ Mottled__ Lunch (time)
Other________________________________________________ Snacks (if - amount per - amount per - amount per serving
any) serving serving
2. Mucous Membranes Dinner (time)
a. Mouth
i. Moist__ Dry__ Snacks (if - amount per - amount per - amount per serving
ii. Lesions: No__ Yes__ Describe: any) serving serving
iii. Color: Pale__ Pink__ Total Fluid ___mL ___mL ___mL
iv. Teeth: Normal__ Abnormal__ Intake
v. Dentures: No__ Yes__ Upper__ Lower__ Partial__ (problems?- ___________________________________________________
cause____________)
vi. Gums: Normal__ Abnormal__
vii. Tongue: Normal__ Abnormal__
ELIMINATION PATTERN
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OBJECTIVE c. Extremities:
1. Auscultate abdomen: i. Temperature: Cold__ Cool__ Warm__ Hot__
a. Bowel sounds: Normal__ Increased__ Decreased__ Absent__ ii. Capillary refill: Normal__ Delayed__
iii. Color: Pink__ Pale__ Cyanotic__ Other__ Describe:
2. Palpate abdomen: iv. Homan’s sign: No__ Yes__
a. Tender: No__ Yes__ v. Nails: Normal__ Abnormal__ Describe:
b. Soft: No__ Yes__; Firm: No__ Yes__ vi. Hair distribution: Normal__ Abnormal__ Describe:
c. Masses: No__ Yes__ Describe: vii. Claudication: No__ Yes__ Describe:
d. Distention (include distended bladder): No__ Yes__ Describe:
e. Overflow urine when bladder palpated? Yes__ No__ d. Heart: PMI location: ________
i. Abnormal rhythm: No__ Yes__ Describe:
3. Rectal Exam: ii. Abnormal sounds: No__ Yes__ Describe:
a. Sphincter tone: Describe:
b. Hemorrhoids: No__ Yes__ Describe: 2. Respiratory
c. Stool in rectum: No__ Yes__ Describe: a. Rate:__ Depth: Shallow__ Deep__ Abdominal__ Diaphragmatic__
d. Impaction: No_- Yes__ b. Have patient cough. Any sputum? No__ Yes__ Describe:
e. Occult blood: No__ Yes__ Location: c. Fremitus: No__ Yes__
d. Any chest excursion? No__ Yes__ Equal__ Unequal__
4. Ostomy present: No__ Yes__ Location: e. Auscultate chest:
i. Any abnormal sounds (rales, rhonchi)? No__ Yes__ Describe: __
SUBJECTIVE f. Have patient walk in place for 3 minutes (if permissible):
1. What is your usual frequency of bowel movements? i. Any shortness of breath after activity? No__ Yes__
a. Have to strain to have a bowel movement? No__ Yes__ ii. Any dypnea? No__ Yes__
b. Same time each day? No__ Yes__ iii. BP after activity: ___/___ in (right/left) arm
iv. Respiratory rate after activity: _______
2. Has the number of bowel movements changed in the past week? v. Pulse rate after activity: _______
No__ Yes__ Increased?__ Decreased?__
3. Musculoskeletal
3. Character of stool a. Range of motion: Normal__ Limited__ Describe:
a. Consistency: Hard__ Soft__ Liquid__ b. Gait: Normal__ Abnormal__ Describe:
b. Color: Brown__ Black__ Yellow__ Clay-colored__ c. Balance: Normal__ Abnormal__ Describe:
c. Bleeding with bowel movements: No__ Yes__ d. Muscle mass/strength: Normal__ Increased__ Decreased__
Describe:
4. History of constipation: No__ Yes__ How often? e. Hand grasp: Right:: Normal__ Decreased__
Do you use bowel movement aids (laxatives, suppositories, diet)? Left: Normal__ Decreased__
No__ Yes__ f. Toe wiggle: Right: Normal__ Decreased__
Left: Normal__ Decreased__
5. History of diarrhea: No__ Yes__ g. Postural: Normal__ Kyphosis__ Lordosis__
h. Deformities: No__ Yes__ Describe:
6. History of incontinence: No__ Yes__ Related to increased abdominal pressure i. Missing limbs: No__ Yes__ Where?
(coughing, laughing, sneezing)? No__ Yes__ j. Uses mobility aids (walker, crutches, etc)? No__ Yes__ Describe:
k. Tremors: No__ Yes__ Describe: Spinal cord injury: No__ Yes__ Level:
7. History of travel? No__ Yes__ ____________________________
4. Paralysis present: No__ Yes__ Where?
8. Usual voiding pattern: 5. Developmental Assessment: Normal__ Abnormal__ Describe:
a. Frequency (times per day) ____ Decreased?__ Increased?__
b. Change in awareness of need to void: No__ Yes__ Increased?__ SUBJECTIVE
Decreased?__
c. Change in urge to void: No__ Yes__ Increased?__ Decreased?__ 1. Have patient rate each area of self-care on a scale of 0 to 4. (Scale has been
d. Any change in amount? No__ Yes__ Increased?__ Decreased?__ adapted by NANDA from E. Jones, et. Al., Patient Classification for Long Term
e. Color: Yellow__ Smokey__ Dark__ Care; User’s Manual. HEW Publication No. HRA-74-3107, November 1974.)
f. Incontinence: No__ Yes__ When? _____________________________ 0 – Completely independent
Difficulty holding voiding when urge to void develops? No__ Yes__ 1 – requires use of equipment or device
Have time to get to bathroom: Yes__ No__ How often does problem 2 – requires help from another person for assistance, supervision or teaching
reaching bathroom occur? _ 3 – requires help from another person and equipment device
g. Retention: No__ Yes__ Describe: 4 – dependent; does not participate in activity
h. Pain/burning: No__ Yes__ Describe:
i. Sensation of bladder spasms: No__ Yes__ When? Feeding__; Bathing/hygiene__; Dressing/grooming__; Toileting__;
Ambulation__; Care of home__; Shopping__; Meal preparation__; Laundry__;
Transportation__
ACTIVITY-EXERCISE PATTERN
2. Oxygen use at home? No__ Yes__ Describe:
OBJECTIVE 3. How many pillows do you use to sleep on?_____
1. Cardiovascular 4. Do you frequently experience fatigue? No__ Yes__ Describe:
a. Cyanosis: No__ Yes__ Where? 5. How many stairs can you climb without experiencing any difficulty (can be
b. Pulses: Easily palpable? individual number or number of flights)?
Carotid: Yes__ No__; Jugular: Yes__ No__; Temporal: Yes__ No__ 6. How far can you walk without experiencing any difficulty?
Radial: Yes__ No__; Femoral: Yes__ No__; Popliteal: Yes__ No__; 7. Has assistance at home for self-care and maintenance of home:
Postibial: Yes__ No__; Dorsalis Pedis: Yes__ No__
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 No__ Yes__ Who? __________ If no, would you like to have or believes needs 1. During this assessment, does patient appear: Calm__ Anxious__ Irritable__
assistance: No__ Yes__ With what activities? Withdrawn__ Restless__
8. Occupation (if retired, former occupation): 2. Did any physiologic parameters change? Face reddened: No__ Yes__; Voice
9. Describe you usual leisure time activities/hobbies: volume changed: No__ Yes__ Louder__ Softer__; Voice quality changed: No__
10. Any complaints of weakness or lack of energy? No__ Yes__ Describe: Yes__ Quavering__ Hesitation__ Other:
11. Any difficulties in maintaining activities of daily living? No__ Yes__ Describe: 3. Body language observed:
_____________________________________________ 4. is current admission going to result in a body structure or function change for
12. Any problems with concentration? No__ Yes__ Describe: ______ the patient? No__ Yes__ Unsure at this time__
13. Kind of physical activity do you engage in?______________
14. Any recent changes in your activities? What brought about such changes? SUBJECTIVE
__________________________ 1. What is your major concern at the current time?
15. Have there been recent negative life events that had their impact on your day- 2. Do you think this admission will cause any lifestyle changes for you?
to-day activities?__________________________ No__ Yes__ What?
16. Are there prescribed movement restrictions? ____________________ 3. Do you think this admission will result in any body changes for you?
17. Any discomfort in movement?_____________ No__ Yes__ What?
4. My usual view of myself is: Positive__ Neutral__ Somewhat negative__
5. Do you believe you will have any problems dealing with your current health
situation? No__ Yes__ Describe:
SLEEP REST PATTERN 6. On a scale of 0 to 5 rank your perception of your level of control in this situation:
7. On a scale of 0 to 5 rank your usual assertiveness level:
OBJECTIVE 8. What type of mood are you usually in? (calm, depressed, pleasant, happy,
excited, agitated) Explore factors which could contribute to sudden changes in
SUBJECTIVE mood.
1. Usual sleep habits: Hours per night ___; Naps: No__ Yes__ a.m.__ p.m.__ 9. What are the things that make you angry? Annoyed? Tearful? Anxious?
Feel rested? Yes__ No__ Describe: Depressed? Explore client’s knowledge and practices in dealing with these
2. Any problems: emotions.
a. Difficulty going to sleep? No__ Yes__ 10. What kind of person are you? (positive/negative) Elaborate.
b. Awakening during night? No__ Yes__
c. Early awakening? No__ Yes__
d. Insomnia? No__ Yes__ Describe: _____________________________ ROLE-RELATIONSHIP PATTERN
3. Methods used to promote sleep: Medication: No__ Yes__ Name: _______
Warm fluids: No__ Yes__ What? __________________; Relaxation OBJECTIVE
techniques: No__ Yes__ Describe: _______________________________ 1. Speech Pattern
4. Describe your feelings after waking up? Refreshed/ fatigued/ lethargic? Do you a. Is English the patient’s native language? Yes__ No__ Native language is:
always feel that way? ______________________ __________________ Interpreter needed? No__ Yes__
5. Describe sleeping environment. Any problems? Concerns? b. During interview have you noted any speech problems? No__ Yes__ Describe:
2. Family Interaction
a. During interview have you observed any dysfunctional family interactions?
COGNITIVE=PERCEPTUAL PATTERN No__ Yes__ Describe:
b. If patient is a child, is there any physical or emotional evidence of physical or
OBJECTIVE psychosocial abuse? No__ Yes__ Describe:
1. Review sensory and mental status completed in health perception-health
management pattern SUBJECTIVE
2. Easiest way to learn things? What are your learning goals?Any difficulties or 1. Does patient live alone? Yes__ No__ With whom?
hindrances to learning? What was done? Effective? Satisfied?____________ 2. Is patient married? Yes__ No__ Children? No__ Yes__ Ages of Children:
3. Any overt signs of pain? No__ Yes__ Describe: 3. Describe relationship to each/other member of the family; how do you feel
about them? When with them, do you often feel happy, hurt, insecure,
SUBJECTIVE rejected, misunderstood, unloved, lonely? Note any observable conflicts
1. Pain between members
a. Location (have patient point to area) : 4. How would you rate your parenting skills? Not applicable__ No difficulty__
b. Intensity (have patient rank on scale of 0 to 10): Average__ Some difficulty__ Describe:
c. Radiation: No__ Yes__ To where? 5. Any losses (physical, psychologic, social) in past year? No__ Yes__ Describe:
d. Timing (how often: related to any specific events): 6. Any family problems you have difficulty handling? (Alcohol/substance abuse by
e. Duration: a member, any Physical Disabilities of a member/presence of illness,
f. What done relieve at home? problems in behavior, decisional
g. When did pain begin? 7. How is patient handling this loss at this time?
8. Do you believe this admission will result in any type of loss? No__ Yes__
2. Decision-making Describe:
a. Decision making is: Easy__ Moderately easy__ Moderately difficult__ 9. Ask both patient and family: Do you think this admission will cause any
Difficult__ significant changes in the patient’s usual family role? No__ Yes__ Describe:
b. Inclined to make decisions: Rapidly__ Slowly__ Delay__ 10. How would you rate your usual social activities? Very active__ Active__
Limited__ None__
3. Knowledge level 11. How would you rate your comfort in social situations? Comfortable__
a. Can define what current problems is: Yes__ No__ Uncomfortable__
b. Can restate current therapeutic regimen: Yes__ No__ 12. What activities or jobs do you like to do? Describe: ___________
13. What activities or jobs do you dislike doing? Describe: _________
SELF-PERCEPTION AND SELF-CONCEPT PATTERN
SEXUALITY-REPRODUCTIVE PATTERN
OBJECTIVE
OBJECTIVE
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Review admission physical exam for results of pelvic and rectal exams. If results 5. Any religious restrictions to care (diet, blood transfusions)? No__ Yes__
not documented, nurse should perform exams. Check history to see if admission Describe:
resulted from a rape. 6. Would you like to have your (pastor/priest/rabbi/hospital chaplain) contacted to
visit you? No__ Yes__ Who?
SUBJECTIVE 7. Have your religious beliefs helped you to deal with problems in the past?
Female No__ Yes__ How?_______________________________
1. Date of LMP:___ Any pregnancies? Para__ Gravida__ Menopause? No__ 8. How important is health to you?
Yes__ Year__ 9. Any spiritual or religious practices important to you? Relevance to
2. Use of birth control measures? No__ N/A__ Yes__ Type: health?
3. History of vaginal discharge, bleeding, lesions: No__ Yes__ Describe:
10. Is religion important in your life? Does this help when difficulties arise?
4. Pap smear annually: Yes__ No__ Date of last pap smear:
5. Date of last mammogram:
6. History of sexually transmitted disease: No__ Yes__ Describe:
GENERAL
If admission is secondary to rape:
1. Is there any information we need to have that I have not covered in this
7. Is patient describing numerous physical symptoms? No__ Yes__ Describe:
interview? No__ Yes__ Comments?
8. Is patient exhibiting numerous emotional symptoms? No__ Yes__ Describe:
2. Do you have any questions you need to ask me concerning your health, plan of
9. What has been your primary coping mechanism in handling this rape episode?
care or this agency? No__ Yes__ Questions:
10. Have you talked to persons from the rape crisis center? Yes__ No__ If
3. What is the first problem you would like to have help with?
no, want you to contact them for her? Yes__ No__ If yes, was this contact of
assistance? No__ Yes__

Male
1. History of prostate problems? No__ Yes__ Describe:
2. History of penile discharge, bleeding, lesions: No__ Yes__ Describe:
3. Date of last prostate exam:
4. History of sexually transmitted diseases: No__ Yes__ Describe:
5.
Both
1. Are you experiencing any problems in sexual functioning? No__ Yes__
Describe:_____
2. Are you satisfied with your sexual relationship? Yes__ No__
Describe:___________________________________________________
3. Do you believe this admission will have any impact on sexual functioning?
No__ Yes__ Describe:

COPING-STRESS TOLERANCE PATTERN

OBJECTIVE
1. Observe behavior: Are there any overt signs of stress (crying, wringing of
hands, clenched fists, etc)? Describe: ____________________________

SUBJECTIVE
1. Have you experienced any stressful or traumatic events in the past year in
addition to this admission? No__ Yes__ Describe:______
2. How would you rate your usual handling of stress? Good__ Average__ Poor__
3. What is the primary way you deal with stress or problems?
4. Have you or your family used any support or counseling groups in the past
year? No__ Yes__ Group name:
Was the support group helpful? Yes__ No__ Additional comments: What do
you believe is the primary reason behind a need for this admission?
5. How soon, after first noting the symptoms, did you seek health care
assistance?
6. Are you satisfied with the care you have been receiving at home? No__ Yes __
Comments:
7. Ask primary caregiver: What is your understanding of the care that will be
needed when the patient goes home?

VALUE-BELIEF PATTERN

OBJECTIVE
1. Observe behavior. Is the patient exhibiting any signs of alterations in mood
(anger, crying, withdrawal, etc.)? Describe: __

SUBJECTIVE
1. Satisfied with the way your life has been developing? Yes__ No__ Comments:
2. Will this admission interfere with your plans for the future? No__ Yes__ How?
3. Religion: Protestant__ Catholic__ Jewish__ Muslim__ Buddhist__ None__
Other:
4. Will this admission interfere with your spiritual or religious practices? No__
Yes__ How?
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