In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed.
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- Ezra Robbins
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1 Name: SS# In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed. Patient Medical, Surgical and Family History Review *Please fill out the following information for your medical record to the best of your knowledge. Thank you for your time. Have you ever had radiation therapy? Yes No If so, when and body location Allergies Please circle: Food Tape Iodine Latex/Rubber Medications *if yes, to what: Other: No known allergies Do you smoke? Yes No Do you currently have homecare services? If so please describe? Nutrition History Recent weight loss? Yes No Special Diet? Please explain: Number of meals per day: Do you consume milk/dairy products? Yes No Do you consume fruits and vegetables? Yes No
2 Please list all your current Medications:*please continue on back side if needed Name of medication dosage amount and time started when General Health: Please circle if you have any of the following: Influenza vaccine current Pneumonia Vaccine current Tetanus vaccine current Glasses or contacts Hearing Aids HISTORY OF MRSA OR VRE? Eyes: circle if present Cataracts Glaucoma Optic Neuritis Retinopathy Ear/Nose/Throat/Mouth: if yes please write date occurred Barotrauma Sinusitis (current or recent) Tinnitus Pharyngitis (current or recent) Dysphagia Ear Tube Placement
3 Respiratory *for remaining sections circle all that apply, please provide dates when acquired Abnormal chest x-ray Acute respiratory distress syndrome Asthma Chronic bronchitis COPD Emphysema Pneumonia Pneumothorax Positive TB (PPD) test Pulmonary embolus Tuberculosis Upper Respiratory Infection (current) Lung Transplant Lobectomy Cardiovascular Buerger s Disease Congestive Heart Failure Coronary Artery Disease Deep Vein Thrombosis (DVT) High Cholesterol High blood pressure Murmur Heart attack Peripheral Vascular Disease Varicose Veins Arrhythmia Venous Insufficiency Venous Disease CABG Heart Transplant LVAd Open heart surgery Pacemaker Stent placement Valve replacement Vein Stripping Gastrointestinal Cirrhosis Crohn s Disease Diverticulitis Eating Disorder Gastric ulcer GERD GI bleed Hemorrhoids Hepatitis Hiatal Hernia Pancreatitis Peptic Ulcer Disease Special Diet Colon Cancer Appendectomy Colectomy Colostomy Ileostomy Fistula site Cholecystectomy
4 Genitourinary BPH Dialysis End stage renal Disease Kidney Disease Kidney stones Menopause Dialysis Prostate Cancer Radiation Cystitis Urinary Tract Infection Breast Cancer OB/GYN Surgery *please explain: Musculoskeletal Arthritis Gout Hip Fracture Osteoarthritis Osteomylitis Osteoporosis Other Fractures Achilles Tendon Lengthening Amputation Back Surgery Foot Surgery Surgical Hardware Joint Replacement Tendon/ligament surgery Hair/Skin/Nails Skin Cancer type: Nail fungal infection Hair loss Skin Fungal Infection Neurological Head or Neck Trauma Epilepsy Head injury with LOC Multiple Sclerosis Stroke TIA Aphasia Neuropathy
5 Psychiatric Alzheimer s Dementia Depression Psychosis Under current psychiatric care Endocrine Adrenal Disease Taking Cortisone Thyroid Disease Type I Diabetes Type II Diabetes Hematologic/Lymphatic Anemia Taking anticoagulants Lymph edema Sickle Cell Anemia Allergic/Immunologic AIDS HIV Positive Immune Deficiency Lupus Reynaud s Disease Rheumatoid Arthritis
6 Family History Disease/Condition Cancer Type: Kidney Disease Thyroid Problems Diabetes Lung Disease Tuberculosis Heart Disease Mental Illness Seizures Hypertension Stroke Family member (Mother,ect) Advanced Directives Advanced Directive provided to hospital Y/N Do not resuscitate order (DNR) provided to hospital Y/N Living Will provided to hospital Y/N Durable power of attorney for healthcare provided to hospital Y/N
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