Get Medical Status

Office of Aging and Adult Services STATEMENT OF MEDICAL STATUS The purpose of this form is to gather current medical information to use in planning services and care for home and community-based services or nursing facilities. Return the completed form to the patient support coordinator ADHC or nursing facility. I. PATIENT INFORMATION Name SS Street Address City Medicaid State II. MEDICAL INFORMATION Diagnoses include ICD9 Primary MRSA Other Medications specify dosage frequency and route Date of Birth Medicare Telephone Zip Code Gender Secondary See Attached May attach patient s Medication Profile additional medications/procedures or medications/procedures prescribed by other physicians Medication Dosage Allergies NKDA Hospitalizations within 2 years include psychiatric None Frequency Route See attached Discharge Summary if applicable Special Care Procedures check appropriate box Give type frequency size stage site etc* as appropriate Respiratory Glucose Monitoring Ventilator Daily Other Injections Daily Other Suctioning/Oral Care Decubitus/Skin Care Daily PRN Stage I Trach Care Daily PRN Urinary Catheter Care Ostomy Care Dialysis Specialized Rehab Type s Number of Minutes Last Week DME Diet/Tube Feeding IVs Seizure Precautions Restraints Home Health skill/frequency/duration Other III. PHYSICAL EXAMINATION INFORMATION Next Week Date of last physical examination Number of NEW orders written in last 14 days Height Pulse Date of last 2 office visits // // Resp Temp General WNL Abdomen WNL Mouth and ENT WNL Extremities WNL Heart and Circulation WNL Ambulation/Gait WNL Genitalia WNL Skin WNL Head and CNS WNL Cognitive include frequency Chest WNL B/P Physician s Name type or print Address Signature Phone Physician or Physician s PA NP RN LPN Date Revised November 26 2007 Replaces December 1 2006 version OAAS-PF-06-009. Return the completed form to the patient support coordinator ADHC or nursing facility. I. PATIENT INFORMATION Name SS Street Address City Medicaid State II. MEDICAL INFORMATION Diagnoses include ICD9 Primary MRSA Other Medications specify dosage frequency and route Date of Birth Medicare Telephone Zip Code Gender Secondary See Attached May attach patient s Medication Profile additional medications/procedures or medications/procedures prescribed by other physicians Medication Dosage Allergies NKDA Hospitalizations within 2 years include psychiatric None Frequency Route See attached Discharge Summary if applicable Special Care Procedures check appropriate box Give type frequency size stage site etc* as appropriate Respiratory Glucose Monitoring Ventilator Daily Other Injections Daily Other Suctioning/Oral Care Decubitus/Skin Care Daily PRN Stage I Trach Care Daily PRN Urinary Catheter Care Ostomy Care Dialysis Specialized Rehab Type s Number of Minutes Last Week DME Diet/Tube Feeding IVs Seizure Precautions Restraints Home Health skill/frequency/duration Other III. MEDICAL INFORMATION Diagnoses include ICD9 Primary MRSA Other Medications specify dosage frequency and route Date of Birth Medicare Telephone Zip Code Gender Secondary See Attached May attach patient s Medication Profile additional medications/procedures or medications/procedures prescribed by other physicians Medication Dosage Allergies NKDA Hospitalizations within 2 years include psychiatric None Frequency Route See attached Discharge Summary if applicable Special Care Procedures check appropriate box Give type frequency size stage site etc* as appropriate Respiratory Glucose Monitoring Ventilator Daily Other Injections Daily Other Suctioning/Oral Care Decubitus/Skin Care Daily PRN Stage I Trach Care Daily PRN Urinary Catheter Care Ostomy Care Dialysis Specialized Rehab Type s Number of Minutes Last Week DME Diet/Tube Feeding IVs Seizure Precautions Restraints Home Health skill/frequency/duration Other III. PHYSICAL EXAMINATION INFORMATION Next Week Date of last physical examination Number of NEW orders written in last 14 days Height Pulse Date of last 2 office visits // // Resp Temp General WNL Abdomen WNL Mouth and ENT WNL Extremities WNL Heart and Circulation WNL Ambulation/Gait WNL Genitalia WNL Skin WNL Head and CNS WNL Cognitive include frequency Chest WNL B/P Physician s Name type or print Address Signature Phone Physician or Physician s PA NP RN LPN Date Revised November 26 2007 Replaces December 1 2006 version OAAS-PF-06-009.