Silverthorne Adult Medical Day Program

23 Geremonty Drive

Salem, NH 03079  (603) 893-4799

 

Name________________________________________DOB_______________________

Medications______________________________________________________________________________________________________________________________________________________________________________________________________________

• Below signature of practitioner certifies that the attached medication list is prescribed by this practitioner and is accurate &valid

Standard Silverthorne Orders:

 

Acetaminophen 500 mg. 2 tabs q 6 hrs. prn               yes                   no        (please circle)

 

Mylanta 30 cc q 4 hrs. prn                                          yes                   no

 

Milk of Magnesia 30ccq 6 hrs.prn                                yes                   no

(followed by 8oz of H2O)

 

May participant self medicate?                                   yes                   no

 

Basic First Aid can be given                                       yes                   no

 

Rehab Screen                                                              yes                   no

 

DNR on file                                                                yes                   no

                                                                        (if  yes a DNR PINK needs to be provided)                                                                                                                                           

 

Diet:    Regular            No added salt             low cholesterol            diabetic______calorie

 

            Low salt          low fat             ground             pureed      other________________

 

Can participant deviate from diet?

 

 

Is participant currently receiving:       Physical therapy  Yes____No___;Occupational therapy  Yes_____No___; Speech therapy Yes___No_____

 

Patient needs Adult Day to monitor mental__________ physical ______________status.

 

Activity restrictions________________________________________________________

 

 

MD Signature_______________________________________Date_________________