PHYSICIAN S REPORT SPECIAL NEEDS Patient s Name: Date of Birth:
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1 Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York PHONE FAX PHYSICIAN S REPORT SPECIAL NEEDS Patient s Name: Date of Birth: Physician s Name: Physician s Address: Telephone: Fax: Acquiring complete medical information is essential in determining if the applicant can complete our program successfully. In addition, the information we are requesting is vital in assessing special needs that could require modification to our program. Please check yes or no for each item in every category and provide explanations when applicable. MEDICAL HISTORY Please answer yes or no and explain when indicated, including details requested as indicated in parentheses. CARDIAC Heart Surgery (type/date) Hypertension Arrhythmia MI (date) CAD SOB Syncope Anemia NEUROLOGICAL Seizures (type/frequency/date of last seizure) TBI (date) Headache/ Migraines (type/frequency) M.S. C.P. (disability) M.R. Stroke (date/residual) ORTHOPEDIC Back Injuries Muscle/Skeletal Disease Fractures (location/ date) Arthritis (type) Chronic Pain Foot/Knee Injuries Shoulder/arm/ wrist injury PULMONARY Asthma SOB Lung Disease Allergies C.P. (disability) Uses O2/ C-Pap 1
2 Patient s name: GI/GU Ulcers Reflux INFECTIOUS DISEASES AIDS HIV Kidney Disease MRSA Liver Gall Bladder Disease Hepatitis (B or C) Rectal Problems Incontinence IBS ENDOCRINE Adrenal Insufficiency Hypothyroidism Diabetes (complete attached sheet) OTHER DISEASES Auto Immune (type) Cancer (date, type) MENTAL HEALTH Diagnosed Mental Illness Psychiatric Hospitalization (date/ diagnosis) Depression Anxiety Dementia/ memory loss Eating Disorder Sleeping Disorder Alcohol - Substance Abuse (Substance/Date of Sobriety) Yes No Explain if Yes Date Attending Physician/Therapist Frequency of Treatment FOR ANY MENTAL HEALTH TREATMENTS LISTED ABOVE Agency/Hospital Address 2
3 Patient s Name: PHYSICAL EXAM HEIGHT: BLOOD PRESSURE: HEARING (Normal or Abnormal): GAIT (Normal or Abnormal): COORDINATION (Normal or Abnormal): WEIGHT: HEART RATE: HEARING AIDS (Yes or No) (left / right): REFLEXES (Normal or Abnormal): FEET (Normal or Abnormal): **** EKG TESTING IS REQUIRED FOR ALL STUDENTS 65 YEARS OLD AND OLDER OR IF CARDIAC DISEASE IS NOTED. **** EKG DATE (Please include report): READING: PLEASE LIST ANY INJURY OR ILLNESS REQUIRING A HOSPITAL STAY IN THE PAST 5 YEARS. Indicate dates/diagnosis/treatments: MEDICATION ALLERGY: PLEASE LIST CURRENT MEDICATIONS: Name of medication Dosage Frequency Route FOOD ALLERGY: RECOMMENDED DIET: 3
4 Patient s Name: FOR DIABETIC PATIENTS A1C BLOOD LEVEL (DATE) : (Required) DIET: _ ORAL MEDICATIONS: INSULIN TYPE AND SCHEDULE: AM: NOON: PM: HS: SLIDING SCALE COVERAGE: INSULIN PUMP: INSULIN PUMP BASAL RATE: UNITS PER CARBOHYDRATE: DOES PATIENT TEST HIS/HER BLOOD SUGAR INDEPENDENTLY? METHOD USED: SCHEDULE OF TESTING: DOES THIS PATIENT INDEPENDENTLY ADJUST INSULIN COVERAGE AS PER YOUR INSTRUCTION? FREQUENCY OF HYPOGLYCEMIC OR HYPERGLYCEMIC REACTIONS: HOSPITALIZATIONS OR EMERGENCY VISITS DUE TO UNSTABLE BLOOD SUGAR LEVELS. PLEASE INDICATE DATES: PLEASE INDICATE SECONDARY COMPLICATIONS AND DEGREE OF SEVERITY: 4
5 Patient s Name: Your Patient has applied to our school for a guide dog through our Special Needs Program. This program provides guide dogs to people with disabilities in addition to loss of vision, including certain developmental and physical challenges. It offers one-on-one training, a pre-selected dog, more flexibility in training and special adaptations of equipment. Each applicant is carefully evaluated during a home visit to identify their special needs. For this program the minimum stamina requirement is walking 4-6 blocks twice daily. Accepted applicants attend an intensive, three week in-residence course. A student s day begins at 6:00 am and ends at approximately 9:00 pm. Each day, students will spend a minimum of 30 minutes in two training sessions working with their guide dog. The day s schedule allows for down time with further accommodations for someone who needs more rest. Guide Dogs typically range in size from 50 to 75 pounds, walk at a minimum speed of 1 to 1 ½ miles per hour and exert a down and forward pull of at least 2 to 3 pounds while working. At times, the dog may get distracted and students may experience sudden brief increases in speed or pull. Students will be assigned a Guiding Eyes dog with a compatible temperament and energy level. In general, Special Needs dogs are more settled, older and easier to control. Many are content doing limited routes. Does this individual suffer from any condition(s) limiting the following: standing, walking, carrying, lifting, stooping, squatting, bending or participating in group interactions? Please specify the condition and recommended restrictions, precautions or modifications: Based on my knowledge of this patient and the information provided to me, it is my opinion that this patient should should not be able to participate in the described course of instruction. Physician s Signature Date of Exam (required) Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York PHONE admissions@guidingeyes.org FAX
PHYSICIAN S REPORT Patient s Name: Date of Birth:
Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York 10598 PHONE 914 243-2216 admissions@guidingeyes.org FAX 914 243-2232 PHYSICIAN S REPORT Patient s Name: Date of Birth: Physician
Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York PHONE FAX
Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York 10598 PHONE 914 243-2216 admissions@guidingeyes.org FAX 914 243-2232 PHYSICIAN S REPORT Patient s Name: Date of Birth: Physician
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2545 W. Hillcrest Dr. #205 Thousand Oaks, CA 91320 Admissions: 888.822.8938 Fax: 805.273.5246 Dear Medical Professional, This patient is seeking care to address eating disorder behaviors. For the patient
New Patient Information
New Patient Information First Name: Last Name: M.I.: Address: City: State: Zip Code: Mobile Phone: Home Phone: Email: Preferred method of communication: Mobile Phone Home Phone Email Date of Birth: Age:
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
PATIENT INFORMATION SHEET (please print) Patient s Name: Birthdate Age. Address: Soc.Sec.# Employer: Address: Phone: Spouse Name: Occupation:
PATIENT INFORMATION SHEET (please print) Today s Date Patient s Name: Birthdate Age First MI Last Address: Soc.Sec.# # and Street City State Zip Telephone # Home:, Work: Occupation: Employer: Address:
**PLEASE NOTE OUR NEW ADDRESS** The Spine Center 159 Wells Ave, Newton, MA Ph: Fax:
Helpful Telephone Numbers Pre-Registration 855-890-9241 Hospital Billing (NWH) 617-726-3884 Physician/Provider Billing (MGPO) 617-726-3884 Web Address nwh.org Pre-Registration Please call up to 7 days
medical questionnaire Date: Day Month Year
medical questionnaire Date: Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name: