Thank you for choosing Holy Cross Outpatient Rehabilitation
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- Marsha Simmons
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1 Thank you for choosing Holy Cross Outpatient Rehabilitation Please complete the attached paperwork prior to your arrival. Ensure you know which facility you are scheduled for. Please arrive 30 minutes prior to your scheduled appointment time to complete registration. If you have any questions please contact the facility 3 (1) Holy Cross Main Hospital PT/OT/Speech 4725 N Federal Highway F: Corner of Commercial Blvd 4 (2) HCMG Orthopedic Institute Holy Cross HealthPlex - PT/OT/Hand 5597 North Dixie Highway F: Between Commercial & Cypress Creek 2 1 (2) Women s Health Rehab Dorothy Mangurian Comprehensive Women s Center - PT 1000 NE 56 th Street F: Off Dixie north of Commercial Blvd (3) HCMG Ortho Institute West Boca PT/OT/Hand 9970 Central Park Blvd #400A Boca Raton F: North of Palmetto (4) West Boca Raton Urgent Care PT State Road 7 (441) Boca Raton F: (5) HCMG Rio Vista PT 1309 S Federal Highway F: South of Davie Blvd, N of I-595 Holy Cross Home Health (1) Zachariah Wellness Pavilion
2 Name: Date: Date of onset of: Injury Problem Surgery State your main reason for therapy: Do you now have, or have you ever had any of the following? High Blood Pressure... Yes No Pacemaker... Yes No Dizziness/Fainting... Yes No Osteoporosis... Yes No Cancer... Yes No Bowel/Bladder Problems... Yes No Kidney Problems... Yes No Stroke/Mini Stroke... Yes No Shortness of Breath... Yes No Heart Problems... Yes No Diabetes... Yes No Seizures... Yes No Fractures... Yes No Circulatory Problems... Yes No Recent Weight Change... Yes No Swallowing Problems... Yes No H/O Falls... Yes No Hip Replacement... Yes No Knee Replacement... Yes No Other... Yes No If YES to any of the above, please explain: Please list any other significant medical diagnoses or conditions: Please list any previous surgical, operative or invasive procedures that you have had: Please list any medications including long term, current, over-the-counter or herbal preparations that you are currently taking: Please describe any known adverse and allergic drug reactions: Is this problem related to a motor vehicle accident? Yes No If YES, when? Have you had this problem before? Yes No If YES, when? If YES, did you receive therapy for this problem? Yes No If YES, what treatment helped you? Has this problem limited your ability to perform everyday task? Yes No If YES, what are they? What are your goals for therapy? Be specific: FORM # /07/07 Page 1 of 1 PATIENT LABEL PATIENT INFORMATION REHABILITATION SERVICES
3 pain ScREEn 1. Do you have pain now? Yes No 2. If no, have you had pain in the last 24 hours or past few days, weeks or months? Yes No If the answer is no to both questions, STOp now! if the answer is YES to either question, continue below: 3. Is the pain you are experiencing of related to your current reason for therapy? Yes No If the answer to question #3 is YES, complete the INITIAL PAIN ASSESSMENT. initial pain assessment Location 1 Location 2 Location 3 Location 4 Location: Where do you have pain? Quality: What does your pain feel like for each location? (throbbing, tender shooting, stabbing, sharp, cramping, burning, aching, heavy, etc.) intensity: On a scale of 0-10 with 0 being no pain and 10 being the worst pain ever, Rate your pain as it feels now. Rate your pain at its best: (0-10) Rate your pain at its worst: (0-10) What is your goal for pain intensity? Time/Frequency: When did the pain start? Is the pain constant (always there) or intermittent (comes and goes)? What positions, situations help alleviate (ease) your pain? What activities or situations aggravate or makes your pain worse? What alternative therapies have you tried? none Cold Heat Massage Other: What works well? Works poorly? all of this information has been reviewed with the patient and/or family: Yes Signature of Person Completing Form Staff Signature Date Date
4 International Prostate Symptom Score (I-PSS) Patient Name: Date of birth: Date completed In the past month: 1. Incomplete Emptying How often have you had the sensation of not emptying your bladder? 2. Frequency How often have you had to urinate less than every two hours? 3. Intermittency How often have you found you stopped and started again several times when you urinated? 4. Urgency How often have you found it difficult to postpone urination? 5. Weak Stream How often have you had a weak urinary stream? Not at All Less than 1 in 5 Times Less than Half the Time About Half the Time More than Half the Time Almost Always Your score 6. Straining How often have you had to strain to start urination? 7. Nocturia How many times did you typically get up at night to urinate? Total I-PSS Score None 1 Time 2 Times 3 Times 4 Times 5 Times Score: 1-7: Mild 8-19: Moderate 20-35: Severe Quality of Life Due to Urinary Symptoms Delighted Pleased Mostly Satisfied Mixed Mostly Dissatisfied Unhappy Terrible If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? 6
5 About the I-PSS The International Prostate Symptom Score (I-PSS) is based on the answers to seven questions concerning urinary symptoms and one question concerning quality of life. Each question concerning urinary symptoms allows the patient to choose one out of six answers indicating increasing severity of the particular symptom. The answers are assigned points from 0 to 5. The total score can therefore range from 0 to 35 (asymptomatic to very symptomatic). The questions refer to the following urinary symptoms: Questions Symptom 1 Incomplete emptying 2 Frequency 3 Intermittency 4 Urgency 5 Weak Stream 6 Straining 7 Nocturia Question eight refers to the patient s perceived quality of life. The first seven questions of the I-PSS are identical to the questions appearing on the American Urological Association (AUA) Symptom Index which currently categorizes symptoms as follows: Mild (symptom score less than of equal to 7) Moderate (symptom score range 8-19) Severe (symptom score range 20-35) The International Scientific Committee (SCI), under the patronage of the World Health Organization (WHO) and the International Union Against Cancer (UICC), recommends the use of only a single question to assess the quality of life. The answers to this question range from delighted to terrible or 0 to 6. Although this single question may or may not capture the global impact of benign prostatic hyperplasia (BPH) Symptoms or quality of life, it may serve as a valuable starting point for a doctor-patient conversation. The SCI has agreed to use the symptom index for BPH, which has been developed by the AUA Measurement Committee, as the official worldwide symptoms assessment tool for patients suffering from prostatism. The SCI recommends that physicians consider the following components for a basic diagnostic workup: history; physical exam; appropriate labs, such as U/A, creatine, etc.; and DRE or other evaluation to rule out prostate cancer.
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Alan Koester, MD Steven Novotny, MD John Jasko, MD Viorel Raducan, MD Brock Niceler, MD Thomas Reinsel, MD Chad Lavender, MD Thank you for choosing Marshall Orthopaedics! We will make every effort to ensure
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1160 Suncast Ln El Dorado Hills, CA
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