SANFORD CENTER GERIATRIC CLINIC

Transcription

1 SANFORD CENTER GERIATRIC CLINIC IDENTIFYING INFORMATION First Name: Last Name: Street Address: Apt: City: State: Zip Code: Phone: Best Time to Contact You: Date of Birth: Age: SSN Gender: Male Female M to F F to M SOCIAL INFORMATION Primary Language: Race/Ethnicity: (Mark all that apply) White Hispanic or Latino Black/African American Asian American Indian/Alaskan Native Native Hawaiian/Pacific Islander Other (Please specify): Marital status: Single Married Divorced Widowed Domestic Partner How many people live in your home including yourself? Do you smoke? Yes No If yes, how much per day, and how many years? Do you drink alcohol? Yes No If yes, how much, and how often? Do you have any cultural or religious customs/practices related to your health care? INSURANCE INFORMATION Do you have Medicare? Yes No Do you have a Medicare supplement? Yes No If yes, which plan? Do you have Medicare Part D? Yes No if yes, what is the name of your Part D Plan? AARP Medicare Rx Humana Senior Care Plus Senior Dimensions Other (Please specify): Do you have Medicaid? Yes No

2 PHYSICIAN INFORMATION Name of Your Primary Care Physician (PCP): Telephone number: Fax number: Date of last appointment: Date of next appointment: List providers who have treated you and/or prescribed medications for you. Attach additional sheets if necessary). Provider Name Reason Date CHIEF COMPLAINT What is your main medical concern? (The reason for visiting this clinic). History of your present illnesses/current conditions: (Events and symptoms you want the clinic physician, social worker or pharmacist to know about your health or your medications). How would you rate your overall health? Excellent Very Good Good Fair Poor MEDICATION HISTORY Do you have any medication allergies? Yes No If yes, which medications? 2

3 Have you experienced unwanted side effects? Yes No If yes, please specify Have there been any recent changes to your medications? Yes No If yes, please specify Are you required to take antibiotics before a procedure? Yes No If yes, please specify List all medications you have discontinued in the past year including reason for discontinuation. Attach additional sheets if necessary. Prescription Medication Name Reason for Stopping Approximate Time when stopped List all current prescription medications that are taken routinely, including medications that are taken on an as needed basis, as well as doctor provided samples. You may include a pharmacy printout of your current prescribed medications and/or attach additional sheets if necessary. Medication Name Strength Number of Times/Day Side Effects Experienced Date Started Reason for Taking List all non-prescription medications, supplements, vitamins and herbal therapies you currently use, including brand names, where appropriate. Medication Name Strength Number of Times/Day Side Effects Experienced Date Started Reason for Taking 3

4 Have you In the Last 12 months PAST HEALTH HISTORY Been admitted to a nursing home? Yes No If yes, how many times? Have you been: (Check all that apply and indicate number of times used) Hospitalized (# of times) Visited an Emergency Room (# of times) Urgent Care (# of times) Walk-In visit to Doctor(# of times) Why did you need emergency or unplanned medical care? (Check all that apply) Heart Attack/abnormal heart beat Congestive Heart Failure Cardiac Stroke Dizziness Falls With Injury Confusion Medication Problems Syncope (Fainting) Hip Fracture Infection (specify) Cancer (specify) Other (specify) Have you had any immunizations recently? Yes No (If yes, check all that apply) Tetanus (date) Influenza (date) Pneumonia (date) Shingles (date) Other (date) During the past 6 months: Did you have any lab work done? Yes No If yes, do you have the lab results? Did you have any X-rays taken? Yes No If yes, of what part of your body? During the past 3 months: Have you fallen? Yes No If yes, how many times? Did any of those falls cause a major injury requiring medical attention? Yes No Did any of those falls cause a minor injury (bruise, cuts) Yes No 4

5 Has a doctor or other health care provider ever cautioned you to do any of the following? (Check all that apply): Gain weight Lose weight Stop drinking alcohol Stop smoking tobacco Exercise Reduce caffeine use Stop recreational drug use Wear seat belt None of these Have you had unintended weight loss? Yes No If yes, describe Have you ever been told by a doctor or other health care professional that you have any of the following medical diagnosis or health conditions? (Check all that apply): High Blood Pressure Heart Attack Heart Failure Stroke High Cholesterol Atrial Fibrillation Alzheimer s Parkinson s Urinary Tract Infection Dementia Depression Arthritis COPD/Asthma Pneumonia Diabetes Neuropathy Vitamin/Mineral Deficiency Sexually Transmitted Infections Gastrointestinal Issues (specify) Cancer (specify) Other (specify) Do you have any reactions with anesthesia? Yes No If yes, describe Do you have any other health conditions that are not listed? Are you frail? Yes No Are you homebound? Yes No Do you have a caregiver? Yes No If yes, who provides your care? If yes, what does he/she do for you? Are you a caregiver? Yes No If yes, for whom do you provide care? If yes, what do you do for him/her? Are you disabled? Yes No If yes, what type of disability? Check all that apply. Physical Sensory Neurological Traumatic Brain Injury Developmental Mental Illness Other (specify): Are you physically limited in any way? Yes No If yes, how? Illness Injury Mental Illness Other Specify): 5

6 Do you need assistance with any of the following activities of daily living (ADLs)? (Check all that apply) Eating Bathing Dressing Toileting Walking Transferring in or out of bed and/or chair None of these Do you need assistance with any of the following instrumental activities of daily living (IADLs)? (Check all that apply) Shopping Housekeeping, light Housekeeping, heavy Laundry Taking your own medications Food preparation Using the phone Using transportation services Money management None of these Do you require the use of any special equipment? (Check all that apply) Check all that apply Cane Walker Hospital bed Special telephone CPAP/Bipap Tub bench Shower chair Bedside commode Wheelchair Oxygen Lifeline Grab bars Trapeze Handheld shower hose Wheelchair (manual or electric) Other NUTRITION ASSESSMENT Without wanting to, I have lost or gained 10 pounds in the last six months. I eat fewer than two meals per day. I have three or more drinks of beer, liquor or wine almost every day. I have tooth or mouth problems that make it hard for me to eat. I don t always have enough money to buy the food that I need. I eat alone most of the time. I take three or more different prescribed or over-the-counter drugs a day. I am not always physically able to shop, cook and/or feed myself. MEDICATION COMPLIANCE Many people do not take their medications exactly as prescribed, for example they eat before taking medication that should be taken on an empty stomach. Have you ever done this? Yes No If yes, please specify: Many people do not take their medications due to unwanted side-effects. Have you ever stopped taking your medications without first talking to your doctor? Yes No 6

7 How do you obtain medications? (Check all that apply) Self-transport to pharmacy Caregiver obtains Doctors samples Mail order to pharmacy Delivery Other (specify): Do you go to multiple pharmacies to buy your prescription medications? Yes No If yes, how many pharmacies? Do you have trouble affording prescribed medications? Yes No If yes, which medication(s)? Do you have someone who manages your medications for you? Yes No If yes, who? What does he/she do for you? How do you remember to take your medications? (Check all that apply) Caregiver administers Directions on prescription label Calendar Pill box or other organizer Other (Specify): When medications are missed, what is the cause? (Check all that apply) Never Missed Don t feel good when taken Expensive Forget Other (Specify): MEDICATION KNOWLEDGE How knowledgeable are you about the medications you are taking? (Check one) Very Knowledgeable Somewhat Not Knowledgeable How knowledgeable are you about the risk factors associated with your medications? (Check one) Very Knowledgeable Somewhat Not Knowledgeable Has your health care provider informed you about possible dependence issues for any of your medications? Yes No Unsure How confident are you that the medications you are taking are appropriate for your current health condition(s)? (Check one) Very Confident Confident Somewhat Confident Not Confident How comfortable are you speaking to your physician(s) about your medications? (Check one) Very Comfortable Comfortable Somewhat Comfortable Not Comfortable Do you understand why you are taking each of your medications? EDGE Yes No Unsure KNOWL 7

8 ADVANCE CARE PLANNING Have you completed any advance care planning documents? Check all that apply Living Will Durable Power of Attorney for Health Care POLST State of Nevada DNR Other, specify None of these If you have a Durable Power of Attorney for Health Care, who is your designee? Name: Relationship: Would you like more information about advance care planning documents? Living Will Durable Power of Attorney for Health Care POLST State of Nevada DNR Other, specify 8