PATIENT INFORMATION Name: Date of Birth: Last First MI Phone number: Relationship to patient

Transcription

1 Alzheimer s and Memory Care Program PATIENT INFORMATION Name: Date of Birth: Last First MI Phone number: CAREGIVER/CONTACT PERSON INFORMATION Name of person completing form if other than patient: Phone Number: Address: Relationship to patient DATE FORM COMPLETED: CONTACT PERSON FOR SCHEDULING APPOINTMENTS: X MARK BOX Patient Caregiver/Contact Listed Above Other: Name Phone number: Address Relationship to patient INSURANCE PLAN NAME: POLICY # GROUP# YOUR MEDICAL PROVIDERS Who are you currently seeing as your primary care physician? Have you seen a neurologist in the last year? Yes - If so, who? Have you had any head imaging completed? Yes - If so, where? Are you currently seeing a psychiatrist, psychologist, or counselor? Yes - If so, who SUMMARY OF YOUR CONCERNS RELATED TO YOUR MEMORY When did you first notice memory issues? What are your particular concerns? What questions do you hope to have answered?

2 Symptoms Please check the box next to the problems that you are experiencing or family is observing Short term memory Delusions (believing Fevers, chills, or sweats problems things that aren t true) Repeats Hallucinations (seeing Vision problems questions/statements or hearing things) Misplaces Personal Items Agitation/aggression or resistance to care Hearing problems or ringing in ears Forgets Depression or sadness Hoarseness Events/Appointments Poor safety awareness Anxiety Swallowing problems Difficulty with finances, Overly happy/silly Dentures numbers or calculations Difficulty making decisions Apathy or low motivation Chest pain or trouble breathing with activity Difficulty planning or organizing Disinhibited, acting socially inappropriate Rapid or irregular heart beat Problems recognizing familiar faces or objects Irritable, mood swings Dizziness or vertigo or lightheadedness Difficulty using simple Repetitive movements, Frequent coughing devices or tools pacing, or tapping Unable to orient clothing to Difficulty falling asleep Indigestion or heartburn body when dressing Word finding difficulty or Frequently waking up at Nausea or vomiting other speaking difficulty night Spelling or writing problems Overly tired during the day or frequent naps Constipation, diarrhea, or other bowel problems Difficulty reading Problems with concentration or attention Paranoid or suspicious Less aware of others feelings Obsessive or compulsive thoughts or behavior Impulsive Rummaging/pillaging in drawers/cabinets Hoarding/hiding objects Significant change in appetite or weight Prefers less social interaction than in past Movements seem slowed down Fatigue / low energy Feelings of worthlessness, hopelessness, or guilt Suicidal thoughts or frequent thoughts of death Loss of interest in previous activities Less concern for hygiene or appearance Joint, neck, or back pain Muscle pain or weakness A fall in the last year or difficulty walking Frequent Headaches Numbness or tingling in arms or legs Tremor or shaking Frequent urination, urinary incontinence, or burning Skin rashes, itching, or bruising Problems with sexual function Page 2

3 Current Employment Status Full time Part Time Retired (year ) Disabled What is/was your career/type of work? Did you or do you have a spouse who served in the military? Yes Marital Status Married Widowed Divorced Separated Never married Cohabitating Present Living Arrangement Alone with: Type of home: (I.e. apartment, single dwelling, two story, etc.) Retirement community Assisted living facility Nursing facility Educational History Less than high school; last grade completed High school grad GED Some college Associate s degree Bachelor s degree Master s degree Doctorate Did you ever repeat a grade, require special education, tutoring, or have difficulty learning? Yes No Current Driving Status Never drive Drive occasionally Drive often Does someone depend on you for transportation? Yes Has your family expressed concern about your driving? Yes Have you limited your driving in any way? Yes Have you had an at-fault crash in the last 5 years? Yes Have you had a citation/ticket/moving violation in the last 5 years? Yes Have you gotten lost when driving in familiar places? Yes Behaviors Tobacco Use: Never used Currently use Quit Amount Type Have you or anyone else been concerned about your current or past use of alcohol or drugs? Yes Current Alcohol use: Beer Wine Spirits ne Frequency of use: Occasional Rare Weekly Daily Estimated number of drinks per day? per week? Do you now or have you ever used recreational drugs such as marijuana, cocaine, heroin? Yes What do you enjoy doing in your free time? Page 3

4 Spiritual/Church Support Yes Faith background or church: Functional Activities Please rate your ability to perform the following tasks by checking the appropriate box. Needs some Activity No help needed assistance/reminders Bathing Dressing (including selecting clothing) Toileting/bathroom Grooming (shaving, teeth, hair) Walking Using the telephone Shopping Cooking/food preparation Housekeeping/Laundry/Yardwork Managing medications Managing money and handling finances Unable to do Available Assistance and Future Planning Do you have children? Yes How many: Are you in contact? Yes Comments: Do you employ someone to provide care or help in your home? Yes If yes, how many days per week: How many hours per day: Do you get help from a family member or friend? Yes If yes, approximately how many days per week: How many hours per day: Is the help you receive sufficient to meet your needs? Yes Do you have any financial concerns regarding costs related to care and/or prescriptions? Yes Who would you call if you were sick and needed help? Do you provide care for a family member? Yes If yes, who? Do you have a medical power of attorney? Yes If yes, please bring a copy to your appointment Do you have a living will? Yes If yes, please bring a copy to your appointment Page 4

5 STOP IF YOUR PRIMARY CARE PHYSICIAN IS PART OF LANCASTER GENERAL HEALTH CARE, WE HAVE ACCESS TO THE ELECTRONIC RECORDS SO COMPLETION OF THE REMAINING PAGES IS NOT NECESSARY MEDICAL HISTORY Circle the specific diagnosed conditions you have- add other conditions you have if not listed Eye and Ear Problems: Cataracts Glaucoma Macular Degeneration Hearing Loss/ Hearing Aid Heart Problems: Heart attack Heart Failure High Blood Pressure Atrial Fibrillation Pacemaker Open Heart Surgery Lung Problems: Asthma COPD Sleep Apnea Bone and Joint Problems: Arthritis Osteoporosis Spinal stenosis Gout Gland Problems: Diabetes Thyroid Overactive (high) Thyroid Underactive (low) Kidney and Urinary Tract Problems: Kidney disease Frequent bladder infections Enlarged Prostate Urinary Incontinence Gastrointestinal Problems: Ulcers Heartburn/hiatal hernia Liver disease/cirrhosis Hepatitis Nervous System Problems: Stroke Dementia or Alzheimer s Disease Parkinson s Disease Epilepsy or Seizures Blood disorders: Anemia Thrombosis/Blood Clots Mental Health Conditions: Anxiety Major Depression Bipolar Disorder Schizophrenia Other: Cancer (Of What) and Treatment: AIDS/HIV Positive History of Syphilis Sexual function problems Seasonal Allergies/Hay Fever Hernia Other Problems: FAMILY HISTORY Please check any illnesses that family members have had Memory loss, dementia, or Alzheimer s disease Anxiety/Depression Father Mother Brother Sister Other blood relative Page 5

6 ALLERGIES Name of Drug/Allergen Reaction: List Medications: Prescriptions; Non-prescription and Natural Products If Separate Medication Sheet Attached Patient uses pill box prepared by pharmacy Name of Drug used What Strength? How do you use it? Regularly (How many? How many times a day?) Example: Tylenol 500 mg. 1 pill 3 times a day Page 6