The OK Health Check. For assessing and planning the Health Care Needs of People with Learning Disabilities. Client Assessment Sheets. Address
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1 The OK Health Check For assessing and planning the Health Care Needs of People with Learning Disabilities Client Assessment Sheets Name (1)... Address Date... fairfield PUBLICATIONS PC Based Record System ISBN David R. Matthews (2nd Edition,1998) (3 rd Edition. 2003) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing from the author.
2 Client s Age (2) Gender (3) Has the client been diagnosed as having a particular clinical syndrome or congenital condition? (4) Date of Previous Health Check (5)... Date of This Health Check (6)... Name of Assessor (7)... Date of most recent full medical examination (8)... Doctor who conducted above examination (9)... Body Measurements Difference +/- 10. Weight last time: 11. Weight now: Height last time: 14. Height now: Waist last time: 17. Waist now: 18. Body Mass Yes No Don't 19. Do you consider the client to be overweight? 20. Do you consider the client to be underweight? Please comment on the above as appropriate.
3 Current Medication (21) The OK Health Check Dosage 22. List the known potential side effects of the above medication for which staff should be alerted to observe. 23. Date of last review of medication Doctor who conducted the review... Pain Yes No Don't 25. When the client experiences pain or discomfort, is he/she able to express it? Please give detail below. 26. Does the client appear to suffer any particular pain or discomfort, frequently, occasionally or periodically? Please give additional details of the above items.
4 Circulation and Breathing Pulse Resp. BP 27. Pulse, breathing and blood pressure at rest. 28. Does the client show any signs of œdema? 29. Does the client ever show signs of cyanosis? 30. Do the client's fingers show any signs of cardiopulmonary disorder? 31. Does the client suffer difficulty breathing or have a troublesome cough? 32. Is the client known to have any congenital or chronic circulatory or respiratory disorder? Yes No Don't 33. Does the client have varicose veins? Details of any investigations Urinary System Yes No Don't 34. Is the client incontinent by day or night? 35. Has the pattern of incontinence changed recently? 36. Does the client appear to have any problem passing urine? 37. Does the client's urine appear abnormally coloured or smell offensive? Please give details of any of the above. Date of the last routine urine analysis...
5 Epilepsy Yes No Don't 38. Does the client have any form of epilepsy? 39. Is an accurate record of seizures maintained? 40. According to those records, has there been any change in the frequency or pattern of seizures recently? 41. Does the client receive anti-convulsant medication? 42. If yes, does this medication require regular blood testing? 43. Are all care staff fully aware of the various potential side effects of the client's anti-convulsant medication? Please give details for any of the above and provide dates as appropriate, state any factors that are known to exacerbate this client's epilepsy. Date of last anti-convulsant medication review... Date of last anti-convulsant blood level tests... Digestion and Elimination Yes No Don't 44. Is the client's diet obviously deficient in any way? Give details below. 45. Does the client receive a 'special' diet for any reason? Give details below. 46. Does this client drink adequate fluids? 47. Does the client frequently suffer constipation or loose motions? 48. Does the client pass abnormally coloured motions? Give details below. 49. Does the client appear to suffer frequent discomfort that might originate in the digestive system or bowel? 50. Does the client have any known chronic digestive condition? 51. Does the client appear to experience any difficulty or reluctance to eat, or have any peculiar eating habits? Please give details of the above, including any investigations. Date of last review of special diet by Doctor or Dietician...
6 Skin Yes No Don't 52. Does the client have any rash, irritation or itching? 53. Does the client have any 'moles' or other marks that were not evident at the last assessment, or which have changed? 54. Do the client's pressure areas become inflamed? 55. Does the client have any damaged or broken skin? 56. Does the client have any chronic or long standing skin condition? 57. Does the client suffer offensive body odour or other personal hygiene problem? Provide further details of the above including any investigations. In your own words, describe the client's complexion. Physique and Mobility Yes No Don't 58. Is the client permanently physically handicapped? If 'yes' please give details below of the extent and nature of this. 59. Is the client's gross motor activity and dexterity impaired? 60. Does the client have difficulty coordinating movement and/or hand-eye coordination? 61. Does the client have a persistently poor posture? Comment on stooping and spinal curvatures. 62. Does the client have contracture problems? 63. Is there any evidence of tremors, twitches or other uncontrolled movements? 64. Does the client suffer any myoclonic spasms? 65. Does there appear to be any particular loss of movement or pain on movement? Comment below. 66. Does the client have any muscle wasting? 67. Does the client have any mobility or positioning aids? If 'yes' please comment on their use and condition below.
7 Physiotherapy Yes No Don't 68. Does the client receive the regular services of a physiotherapist? Comment on the above 'Physique and mobility' items and provide further details as appropriate. State if attention is needed to any aids used by, or which might be useful to this client. Date of last physiotherapy review... Name of Physiotherapist... Feet Yes No Don't 69. Is there an obvious problem in relation to the shape of the feet? 70. Is there any evidence of skin problems on the feet or between the toes, any signs of itching or discomfort? 71. Are the toe nails thick, mis-shapen or abnormal? 72. Does the client appear to have any pain in the feet? 73. Is the client known to have a chronic foot condition? 74. Is there any evidence of circulation problems to the feet? 75. Is a chiropodist involved in the client's footcare? Date of last chiropodist appointment... Name of chiropodist...
8 Oral Hygiene Yes No Don't 76. Does the client have regular dental checks? 77. Does the client have any teeth? Comment below. 78. Is there any obvious problem with teeth or gums? 79. Does the client appear to have any difficulty chewing? 80. Does the client have persistently offensive breath? 81. Does the client dribble excessively? 82. Does the client have any chronic mouth condition? 83. Does the client have frequent mouth sores or ulcers? 84. Does the client appear to have painful or sensitive teeth? 85. Does the client have dentures? 86. If 'yes', does the client wear them? Date of last dental examination... Name of Dentist... Eyes and Vision Yes No Don't 87. Does the client have any obvious eye/vision defect? 88. Does the client have any obvious opacity of the eyes? 89. Is there any behaviour which might suggest the client has discomfort or other problem of the eyes? 90. Is their any behaviour which suggests problems of vision? 91. Does the client appear suffer discomfort in respect of the eyelids? 92. Does the client wear spectacles? If 'yes', comment on condition. 93. Has the client had their eyes and vision checked? Give details of any of above eye and vision items. Date eyes and vision last checked... Name of ophthalmic practitioner...
9 Ears and Hearing Yes No Don't 94. Does the client have any obvious ear problem? 95. Does the client's behaviour suggest a hearing problem? 96. Does the client have a history of ear problems? 97. Does the client have any impacted or excess ear wax? 98. Have the client's ears and hearing been checked? 99. Does the client use a hearing aid? If 'yes' comment on its use and condition Does the client appear to have any balance problems? Date of last ears/hearing examination... Sexual Health - Female Yes No Don't 101. Has the client had a breast examination? Give details Has the client had a cervical smear? Give details Does the client menstruate regularly? 104. Does the client appear to experience any physical or psychological problems with her menstrual cycle? 105. Does the client appear to have any frequent or periodic itching or discomfort of the anus, perineum or genitals? Comment on the above and any sexual activity that is likely to benefit from health promotion. Details of examinations......
10 Sexual Health - Male Yes No Don't 106. Has the client had a testicle/genital examination? Give details Does the client frequently dribble after passing urine? 108. Does the client appear to have any frequent or periodic itching or discomfort of the anus or genitals? Comment on the above and any sexual activity that is likely to benefit from health promotion. Details of examinations Sleep Yes No Don't 109. Does the client have a disturbed sleep pattern? 110. Does the client often stay awake much of the night? 111. Does the client often sleep much of the day? 112. Does the client use night sedation to assist sleep?
11 Mental Health Yes No Don't 113. Does the client appear to experience frequent emotional distress? 114. Does the client display apparently irrational mood swings? 115. Does the client appear to experience altered perceptions? 116. Does the client appear to have any irrational fears or anxieties? 117. Does the client indulge in any obsessional behaviours? 118. Does the client suffer from any psychosomatic disorders, or any physical condition that does not appear to have a cause, despite investigation? 119. Does the client appear to suffer frequent or periodic headaches? Date of most recent psychiatric review... Name of Psychiatrist... Lifestyle Risks Yes No Don't 120. Does the client take sufficient regular exercise? 121. Does the client indulge in any behaviours likely to threaten health? 122. Does the client have any habits that are likely to pose a threat to health? (Smoking etc) 123. Does the client indulge in self injurious behaviours?
12 Stressors Detail any specific stressors the client may currently be experiencing. The OK Health Check Other Health Issues Comment on any issues not detailed elsewhere, or elaborate on any issues as necessary. Summary Briefly summarise the items which require further action or investigation.
13 Action Plan Briefly detail immediate, high priority actions, and interventions that are necessary. Referrals and investigations required Signed... Assessor Signed... Supervising Manager Fairfield Publications P.O. Box 310, Preston Central, PR1 9GH, England.
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1 A B O U T Y O U Full Name: Welcome to Voller Dentistry. We d like to get to know you better so that we can do our best to ensure your total oral health! Marital Status: Spouse s Name: Spouse s Occupation:
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form Patient Information Name: Date of Birth: Age: Gender(please circle) M or F Occupation: Address: City, State, Zip: Email: Home Phone: Cell
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
Allan Warshowsky MD,FACOG, ABIHM. New Patient Questionnaire Date of appointment :
New Patient Questionnaire Date of appointment : Name: Address: Apt# City: State: Zip: Phone: Cell: Email: Age: DOB: Referred By: Your occupation: Allergies: To Medications: Other: Reason for Today s Visit:
Enquiry Severity Immediate or other. Joint or muscle pain - any part of the body. Abdominal pain Acute Non-acute. Acne Anxiety Acute Non-acute
We operate a hybrid triage system offering a mixture of telephone consultations, on the day emergency consultations with a doctor or pre bookable (3 days in advance) GP / Nurse Practitioner appointments
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
Pure Health Natural Medicine
Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
Charleston Hematology Oncology Associates, PA Medical History
Charleston Hematology Oncology Associates, PA edical History Patient Name: amily History Date of Birth (Please write in names) If Living: If Deceased: Age Health Age at Death Cause of Death ather other
PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS
UF Health Senior Care PO Box 100383 Gainesville, FL 32608 352-265-0615 Fax 352-294-5803 PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS Please complete this questionnaire at home and bring it with you to the
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
Consent for Treatment Form
Consent for Treatment Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist at Nourish: Healing
HISTORY PAPERWORK FOR APPOINTMENTS WITH DAVID A. PROPST, D.O.
HISTORY PAPERWORK FOR APPOINTMENTS WITH DAVID A. PROPST, D.O. Name: Age: Room Number: Sex: MALE or FEMALE Dominant Hand: RIGHT or LEFT Height Weight Blood pressure HISTORY 1. Did your first symptoms begin
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex