Rainbow Homes Travel Club Medical and Health History Form 2111 Adelpha Ave. Holt MI (517)
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1 Rainbow Homes Travel Club Medical and Health History Form 2111 Adelpha Ave. Holt MI (517) PERSONAL Name: DOB: First Middle Last Preferred Seizures: Yes No Gender: Male Female Religion: Allergies (Medications, Latex, Bandaids, Food, Bee Stings, & Environmental Etc): Reactions: Carry an Epi Pen? Yes No Know how to use an Epi Pen? Yes No Group Home Name/Support Staff: Group Home #: Personal Address: Phone #: Cell Phone #: Social Security #: State ID #: SUPPORTS CMH #: Case Manager: Phone #: Guardian: Relation: Phone #: Payee/Conservator: Relation: Phone #: Emergency Contact: Relation: Phone #: INSURANCE INFORMATION Medicaid #: Medicare #: Part A: Part B: Other Insurance Co.: Policy # Group # Prescription/ Drug Plan #: RX Group: RXBIN: RXPCN: Issuer: Other Insurance Information: Page 1 of 5
2 MEDICAL Medical Diagnosis: Mental Health Diagnosis: Primary Doctor: Doctor Phone #: Height: Weight: ON-GOING CARE, (Please check all that apply) Hepatitis A, B, C Sleep Apnea Diabetes Emotional Issues Bowel Issues Heart Conditions Acid Reflux Prostrate Issues HIV / AIDS Urinary Issues Cancer Arthritis Asthma Chronic Ear Issues Skin Issues STD s Other Please Explain: ASSISTIVE DEVICES (Please check all that apply) Hearing Aids Glasses/Contacts Dentures Brace/AFO Cane Walker Comp. Stockings Shower Chair C-Pap or Bi-Pap Sleep propped up Under Garment Protection Day Night Both Wheel Chair All day Long distance only Bringing own Wheel Chair? Yes No If bringing own wheelchair please note if collapsible Other Please Explain: DIETARY NEEDS Diabetic Diet Low Salt Low Fat Reduced Calorie Diet Needs Food Cut Up Other Dietary Concerns Page 2 of 5
3 ASSISTANCE/REMINDERS (Please fill in R for Reminders and A for Assistance) Showering Brushing Teeth Shaving Not Over Eating Healthy Choices Wandering from Group Going to Bed / wake up Use Restroom Keeping track of belongings Changing to Clean Clothing Choosing Appropriate Clothing Taking Medication (explain) Other assistance needed, please describe: OTHER Drinks Alcohol Frequent or Problem Drinker Smoke Chews Tobacco Use of Recreational drugs _ PREFERRED WAKE UP METHOD Set Alarm Call Phone or Room Name Spoken Gentle Touch MONEY (How much money can Traveler have on their person at a time?) None $5.00 $10.00 $15.00 $25.00 more than $25.00 Uses a Debit or Credit Card PERFERRED OVER THE COUNTER MEDICATION (OTC) IF NEEDED Pain or Head Ache Tylenol/Acetaminophen Motrin/Ibuprofen Naproxen/ Aleve Other: Stomach Ache Anti Diarrheal Motion Sickness Cough / Cold Menstrual Issues Tums Pepto Bismo or Other: Imodium or Other: Dramamine or Other: Day/ Nyquil Coricidin (High Blood Pressure) or Other: Midol Ibuprophen/ Motrin Or Other: Please List any other OTC that may be given: Page 3 of 5
4 MEDICATIONS (Attach Additional Medication list) SURGERIES/PAST HOSPITALIZATIONS (Include any Psychiatric Hospitalizations) When: When: When: When: VACCINES TB : (+ or -) Flu Vaccine: : Tetanus Vaccine : Pneumonia Vaccine : Please also include a copy of Traveler s State ID as well as any Insurance Cards or information. Please sign this below stating that you have filled this form out to the best of your medical knowledge. Page 4 of 5
5 Emergency Release This is authorization for Rainbow Homes or its Agents to seek emergency medical treatment in case of serious accident or illness, or to make whatever arrangements necessary to meet immediate health needs. I understand that Rainbow Homes Bears No Financial responsibility for the emergency services secured on my ward behalf. By signing this form, I also understand that I am authorizing the release of medical information concerning me/my ward. This may include information regarding AIDS, AIDS related complex (ARC), Human Immunodeficiency Virus (HIV), or other communicable diseases for the purpose of providing appropriate care or services for me/ my ward. I understand that this information is to be used for the stated purposes only and is valid for only two years. I understand that I can withdraw my permission at any time. The Photo release is optional. The facilitators and volunteers of Rainbow Homes take pictures during Travel Club trips and activities to record events, provide documentation for grants and provide pictures for education. The Rainbow Homes facilitators will do their best to notify you of any picture(s) or videos to be used by any local media/ news station when you have agreed to picture/ video. At no time will the Rainbow Homes facilitators or volunteers take pictures that appear inappropriate. For Rainbow Homes Office use only. Received : By: Health Form Expires (2 years from received year) Dropbox/Forms 1/Trips/Trip Forms/Health From 2016 Revised 2/18/16 Page 5 of 5
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PATIENT REGISTRATION FORM PLEASE PRINT : Referring Physician: Primary Care: Patient s Name: Last First: M.I. Address: City: State: Zip: Home Phone: Cell: Work: Email: Preferred Contact Method Race: Ethnicity:
Children s Residential Treatment Center Medical Intake Information
Children s Residential Treatment Center Medical Intake Information The following is required at/by intake: q Copy of Current Insurance Cards (Medical, Dental, or Medical Assistance) q Proof of Physical
Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
Entrance Case History (Please write or print clearly)
Stony Brook Medical Park 2500 Nesconset Highway Suite 4-A Stony Brook, NY 11790 (631) 675-9000 Fax (631) 675-9002 www.naturalapproach.us Entrance Case History (Please write or print clearly) Today s Date
Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country
Hoover Hearing Clinic A division of Hoover ENT Hoover, Alabama 35244 205-733-9694 Tel PATIENT INFORMATION ACCOUNT # DATE MD NEW UPDATE Patient s Full Name DOB Age Patient s SSN Sex: Male Female Preferred
PRESCRIBING PHYSCIAN ONLY.
Return All Forms To: Administrative Address 985 Livingston Avenue North Brunswick, NJ 08902 Direct Phone/Fax: 732-737-8279 info@campjaycee.org Camp Address 223 Ziegler Road Effort, PA 18330 Phone: 570-629-3291