Hospital Name. Medical Record Number: Hours/Days of Operation: Clinic: Physician: Contact Person / Title: Phone: Fax: Hours/Days of Operation:

Transcription

1 Hospital Name City, State, Zip Code: Phone Numbers: Main Number: Emergency Room: Medical Record Number: Clinic: Hours/Days of Operation: Physician: Contact Person / Title: Phone: Fax: Clinic: Hours/Days of Operation: Physician: Contact Person / Title: Phone: Fax: Clinic: Hours/Days of Operation: Physician: Contact Person / Title: Phone: Fax:

2 Medical / Dental Community Health Care Providers Primary / Community Care Provider: Office Nurse: Community Hospital: Medical Record Number: Community Specialty Care Provider: Community Specialty Care Provider: Dentist / Orthodontist:

3 Home Care Community Health Care / Service Providers Home Nursing Agency: Start Date: Contact Person: Home Nursing Agency: Start Date: Contact Person: Home Nursing Agency: Start Date: Contact Person:

4 Therapists Community Health Care / Service Providers Therapists: Occupational Therapist (OT) Start Date: Agency: Physical Therapist (PT): Start Date: Agency: Speech-Language Pathologist: Start Date: Agency:

5 Pharmacy Community Health Care / Service Providers Pharmacy: Hours/Days of Operation: Contact Person: Pharmacy: Hours/Days of Operation: Contact Person: Pharmacy: Hours/Days of Operation: Contact Person:

6 Special Transportation Community Health Care / Service Providers Transportation (to and from medical / therapy appointments) Contact Person: Agency: Transportation (to and from medical / therapy appointments) Contact Person: Agency:

7 Family Information Your Name: Nickname: Date of Birth: Diagnosis: Blood Type: Legal Guardian: Phone: Family Members Mother s Name: Daytime Phone: Evening Phone: Cell: Father s Name: Daytime Phone: Evening Phone: Cell: Sibling s Name: Age: Name: Age: Name: Age: Name: Age: Other Household Members: Important Family Information: Language Spoken at Home: Other Language(s): Interpreter Needed? Yes: Interpreter: No: Phone: Emergency Contact Name: Daytime Phone: Evening Phone: Cell:

8 Insurance/Funding Sources Insurance Company: Policy Number: Contact Person / Title: Insurance Company: Policy Number: Contact Person / Title: Insurance Company: Policy Number: Contact Person / Title: Supplemental Security Income (SSI): Contact Person / Title: (continued)

9 Insurance/Funding Sources Other: Contact Person/Title: Other: Contact Person/Title:

10 Care Schedule TIME Morning CARE Afternoon

11 Care Schedule TIME Evening CARE Night

12 Appointment Log DATE PROVIDER REASON FOR APPOINTMENT / CARE PROVIDED NEXT APPOINTMENT

13 Medical / Surgical Procedures DATE PROCEDURE RESULTS COMMENTS

14 Lab Work / Tests / Procedures DATE TEST RESULTS COMMENTS

15 Equipment / Supplies Name of Equipment: Description (brand name, model, size, etc.): Date obtained: Supplier: Contact Person: Phone: Serial Number: Name of Equipment: Description (brand name, model, size, etc.): Date obtained: Supplier: Contact Person: Phone: Serial Number: Name of Equipment: Description (brand name, model, size, etc.): Date obtained: Supplier: Contact Person: Phone: Serial Number: Name of Equipment: Description (brand name, model, size, etc.): Date obtained: Supplier: Contact Person: Phone: Serial Number:

16 Medications Allergies: Pharmacy: Phone: MEDICATION DATE STARTED DATE STOPPED DOSE / ROUTE (with or without food?) TIME GIVEN PRESCRIBED BY

17 Diet Tracking Form DATE SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY Tube Feeding Breakfast Lunch Dinner Snacks Notes

18 Hospital Stay Tracking Form DATE HOSPITAL REASON NOTES

19 Medical Bill Tracking Form DATE PROVIDER COST INSURANCE PAID DATE PAID FAMILY OWES DATE PAID

20 MAKE-A-CALENDAR Month Year SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

21 Notes