OUTPATIENT ASSESSMENT SMMC: Page 1 of 5 Adopted Date: Revised Date: 10/02; 6/04; 11/04 Reviewed Date: Name Birthdate Phone Number:
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1 Name Birthdate Phone Number: Dear Patient and Family, Please answer the following questions. Your answers will help your health care team plan and give care to you or your significant other. A nurse will review this form with you after it is filled out. If you are unclear on any questions or need assistance, leave it blank and the nurse will assist you. Thank you, St. Mary s Medical Center PATIENT LEFT COLUMN ONLY INFORMATION ABOUT THE PATIENT NURSING USE ONLY Information provided by: Patient Nursing staff Family member/friend Other Date: Nurse s Signature: NOTE: *Protocol may require testing NURSING ASSESSMENT/ INTERVENTION 1. Why are you coming to the medical center? Age Height Weight 2. Do you have any allergies/reactions to drugs, food, latex (rubber), dye or environmental? Yes, please list No ALLERGY TYPE OF REACTION 3. List medications currently taken (include over the counter nonprescription meds, herbs, and vitamins). * DRUG (Medicine) DOSE (Strength) How Often SMMC: Page 1 of 5 Procedure: Date/Doctor: PRIMARY PHYSICIAN Consent H&P Labs CXR EKG Stress Test Patient instructed not to take aspirin, NSAID 1 week prior to surgery. Office instructed to take the following meds: * NOTE: Chem 7 may be required by protocol if taking diuretics or digitalis
2 4. Do you have any of the following: (present and past history) * High/low blood pressure * Chest pain * Heart attack * Heart skips beats/races * Heart failure * Circulation problems * Passing out spells * Blood clots * Lung problems/disease * Shortness of breath Wheezing * Emphysema/Asthma (COPD) * Black lung * Asbestosis * Pneumonia * Bronchitis Cold within last week * Vomiting * Heartburn Reflux (food/liquid comes back up in throat) Ulcers Hiatal hernia * Kidney disease * Urinary tract infection Kidney stones Bowel problems * Diarrhea/Constipation Diabetes (high sugar) Thyroid problems Stroke/Paralysis Seizures Head injury Neck/back problems Arthritis * Free bleeder not related to medication Liver problems/hepatitis/cirrhosis/jaundice Anemia Have you ever had a blood transfusion? If yes, did you have a reaction to that transfusion? Chicken pox? If yes, when? Tuberculosis (TB), positive TB test, unexplained weight loss, temperature or coughing up blood, mucus for 3 weeks or more, night sweats Cataracts/glaucoma Ear infections Heart murmur Mitral Valve prolapse Rheumatic fever Y / If yes to any of the above, do you require prophylactic antibiotics? Do you have an AICD/pacer: If yes notify the OR N Yes No Date/time/person notified Any Yes Answers respond below: * Note may require testing by protocol. SMMC: Page 2 of 5 Revised Date: 10/02; 6/04;11/04
3 4. Do you have any of the following: CON T (present and past history) History of cancer? If yes, type Have you smoked in the past 12 months. If so, when did you stop? Do you smoke? If yes, how much and how long? Do you use alcohol or illegal drugs? If yes, what/ amount? * Chance of pregnancy? Last menstrual period 5. List your previous surgeries, dates, hospitals below: Surgery Date Hospital 6. Type Anesthesia received in the past: General (put to sleep) Epidural Spinal Other 7. Have you or any family member had trouble/problems with anesthesia: Yes No If yes, check what applies: nausea/vomiting high temperature after surgery memory loss due to anesthesia 8. Do you have anyone to help you when you get home? Yes No Person to be notified regarding discharge plans or in case of emergency. Obtain old record, report the necessary information to the anesthesia department. Verify responsible adult for 24 hours and a driver to accompany patient. Name (Relationship) Phone(home) (Work) Name (Relationship) Phone(home) (Work) 9. Do you live: Alone With Spouse Other Do you have (check all that apply) Indoor plumbing Phone Stairs Electricity Gas Heat 10. Do you have any of the following? Hearing aids L/R Glasses Dentures upper/lower Partial plate upper/lower Bridges/caps/crowns Chipped/loose teeth Walker Cane Crutches Wheelchair Oxygen Artificial limbs/braces SMMC: Page 3 of 5
4 12. Do you have any special diet or use dietary supplement? Yes No If yes, list: 13. Are you or anyone in your home being hurt, hit, threatened, frightened or neglected? Yes No 14. Do you think you might have trouble: (please check all that apply): Managing your care (bathing, cooking, taking meds, care at home after discharge) Paying for medications Paying for hospitalization Having someone to care for you at home Getting a ride for discharge/return appointment I do not expect any problems. 15. Advanced Directives Have you made arrangements for how medical treatment should be applied or withheld if you were to become unable to make your health care decisions? (Advance Directives). Are these arrangements in writing? (If no, provide packet) Have you made arrangements for another person(s) to make medical decisions on your behalf if you are unable to communicate. Are these arrangement in writing? (If no, provide packet) If yes, initiate social service referral and document: Date/time: Name: Control Number: Refer to social services or patient accounts representative: Date/time: Name: Control Number: If answered yes informed to bring copy for chart. If answered no would you like to execute either form at this time? Yes No Admission packet with forms given to patient. Trusted representative Intent *** If the patient is confused or comatose and no valid medical power of attorney exists, the physician is to be notified regarding possible surrogate appointment. MD Notified: Date/Time: SMMC: Page 4 of 5
5 Diabetic Assessment: Are you diabetic? YES, (If YES complete the following questions. NO Do you know how to manage high blood sugar? Yes Not applicable Do you know how to manage low blood sugar? Yes Not applicable Do you know how to take your diabetes pills? Yes Not applicable Do you take your insulin regularly? Yes Not applicable Are your injections given without problem? Yes Not applicable Are your injection sites changed regularly? Yes Not applicable Do you check your feet daily for problems? Yes Not applicable Do you know what to do about your diet, medications when sick? Yes Not applicable Do you know about long term complications of diabetes? Yes Not applicable Do you need to see a dietitian for help with meal planning? Yes Not applicable Do you need to learn to check your blood sugar? Yes Not applicable Do you need a blood sugar monitor? (Yes requires a Social Service Consult) Yes No Do you need monitor supplies? (Yes requires a Social Service Consult) Yes No Do you need syringes? (Yes requires a Social Service Consult) Yes No NURSING USE ONLY Nutrition State: No nutritional risk Oral lesions TF or TPN, PPN Chewing/mouth problems Early satiety Poor PO 5 days/more Taste change No teeth Swallowing difficulty Unintentional wt. loss > l0lbs. Poor dentition Chemo/radiation Avoids certain foods SMMC: Page 5 of 5 1/4/2005 3:06 PM
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Initial Pool Process: Resident Interview Care Area Probes Response Options Choices Are you able to make choices about your daily life that are important to you? I d like to talk to you about your choices.
PATIENT REGISTRATION FORM Please Print
PATIENT REGISTRATION FORM Please Print Patient Name: Gender: Male Female Birth Age: Social Security #: Address: City, State, Zip: Home Phone #: Cell Phone #: Email: If under 18, Parent/Guardian: Parent/Guardian
Welcome to Pinnacle Chiropractic Spine and Sports Center
Welcome to Pinnacle Chiropractic Spine and Sports Center Name: Social Security Number: : Address: City: State: Zip: _ Telephone Home: Work: Mobile: _ Age: of Birth: Height: Weight: Gender: M / F Employer:
Thompson Medical Group New Patient Registration Form
Thompson Medical Group New Patient Registration Form PLEASE PRINT Last Name: First Name: MI: Sex: Male / Female Date of Birth: Age: Race (i.e. Caucasian/Hispanic/Asian): Ethnicity (i.e. American/Mexican/German):
I acknowledge I have read and understand this office s Notice of Privacy Practices. (A copy can be furnished to you at your request)
Patient s name: Email Address: Do you wish to receive emails with special offers/newsletters? Yes No I acknowledge I have read and understand this office s Notice of Privacy Practices. (A copy can be furnished
Welcome to Pinnacle Chiropractic Spine and Sports Center
Welcome to Pinnacle Chiropractic Spine and Sports Center Name: Social Security Number: : Address: City: State: Zip: _ Telephone Home: Work: Mobile: _ Age: of Birth: Height: Weight: Gender: M / F Employer:
Virginia Heartburn & Hernia Institute
Virginia Heartburn & Hernia Institute PATIENT INFORMATION FORM (Please make sure to print clearly and sign at the bottom of this page) Patient s Last Name: First: Middle Initial: Marital Status: Married
Patient Registration Form
Patient Registration Form Please Complete the Following Information-Thank You Patient Information: Name: Last First MI Address: City: State: Zip: Home Telephone: Work Telephone: Best to Reach? Home? Work?
NURSING HOME PRE-ADMISSION ASSESSMENT FORM
Clients Name: NHS No AIS No (if applicable) DOB: Home Address NOK Contact Details Telephone: Relationship: Other contact: Marital status Religion GP Details and Address Ethnic origin Date of Referral:
Department of Internal Medicine Division of Cardiology
Department of Internal Medicine Division of Cardiology APPOINTMENTS: (813) 259-0600 TOLL FREE: (888) USF-DOCS WEB: www.usfdocs.com Provider: Appt. Date: Appt. Time: We1come to the University of South Florida
PROVIDENCE MOUNT ST. VINCENT Hand In Hand Assisted Living Apartments Residency Application/Pre-Admission Assessment I.
PROVIDENCE MOUNT ST. VINCENT Hand In Hand Assisted Living Apartments Residency Application/Pre-Admission Assessment I. BASIC INFORMATION Name First Middle Last What you prefer to be called: DOB: Age: Today
Las Vegas, NV FAX: [INCOMPLETE APPLICATIONS CANNOT BE PROCESSED AND WILL BE RETURNED]
![Las Vegas, NV FAX: [INCOMPLETE APPLICATIONS CANNOT BE PROCESSED AND WILL BE RETURNED]](/thumbs/89/98344726.jpg "Las Vegas, NV FAX: [INCOMPLETE APPLICATIONS CANNOT BE PROCESSED AND WILL BE RETURNED]")
Honor Flight Southern Nevada Veteran Application and Medical Form Honor Flight Southern Nevada recognizes America s most senior war veterans for their service and sacrifice by flying them (all-expense-paid