Date________________Referral Source______________Admission Date_______

Name__________________________________________ Phone___________________

Address_____________________________________________Relig________________

Lives with_________________________________________Phone_________________

Email address_______________________________________

DOB__    /__    /__    Age______    Marital Status: S    M    W    D     Sex:  M    F

 

Medicare # and Insurance___________________________________________________

Medicaid #______________________________________________________________

Social Security #________________________________________________________

 

Next of Kin:

Name________________________________ Relationship________________________

Address_______________________________ Telephone # home___________________

____________________________________                      work____________________

                                                                                              cell____________________

Physician_______________________Phone___________________Fax______________

Address__________________________________________Hospital________________

Diagnosis_______________________________________________________________________________________________________________________________________

Treatment and medications: _________________________________________________

________________________________________________________________________

Allergies________________________________________________________________

Medical Alerts____________________________________________________________

            Self      Assist  Dependent                               Vision             Legally blind

                                                                                    Speech

Dressing____________________                              Hearing

Walking____________________                               Contractures

Bathing_____________________                             Extremities

Eating______________________                              Paralysis

                                                                                    Amputation     AK             BK

                                                                                    Understanding

Equipment:      Walker Cane    Wheelchair      Hearing Aid    Glasses            Dentures

Mental Status: Alert    Noisy   Confused        Depressed       Withdrawn

Bladder: Continent     Incontinent                  Bowel: Continent        Incontinent

Skin Condition:           Clear    Rash    Ulcers  Tumors

Diet:_________________________WT.__________________HT.__________________

DHHS Caseworker:________________________________Phone__________________

Home Health Agency__________________________________RN_______Aide______

Contact Names/Numbers____________________________________________________

Living arrangements (stairs etc..)_____________________________________________

Social and Emotional Factor_________________________________________________

Endurance:______________________________________________________________

Education_________________________Previous Occupation______________________

Advanced Directives: DPOA Y    N      Living will:   Y    N Info given:     Y    N