MEDIESE SERTIFIKAAT / MEDICAL CERTIFICATE AANSOEK OM OPNAME IN TUISTE VIR BEJAARDES APPLICATION FOR ADMISSION TO HOME FOR THE AGED

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Transcription:

MEDIESE SERTIFIKAAT / MEDICAL CERTIFICATE AANSOEK OM OPNAME IN TUISTE VIR BEJAARDES APPLICATION FOR ADMISSION TO HOME FOR THE AGED (MOET DEUR MEDIESE PRAKTISYN VOLTOOI WORD / MUST BE COMPLETED BY MEDICAL PRACTITIONER) VOLLE NAME VAN APPLIKANT / FULL NAMES OF APPLICANT GEBOORTEDATUM / DATE OF BIRTH IDENTITEITSNOMMER / IDENTITY NUMBER RAS / RACE. GESLAG / SEX ALGEMEEN / GENERAL LENGTE / HEIGHT GEWIG / WEIGHT SPYSVERTERINGSTELSEL / ALIMENTARY SYSTEM SLEGTE SPYSVERTERING / INDIGESTION MANTELVLIESBREUK / HIATUS HERNIA. KLAGTES / COMPLAINTS... SPESIALE VOEDING / SPECIAL DIET

GESIGSVERMOë / VISION OOGPêRELS / CATARACTS GLOUKOOM / GLAUCOMA GESIGSVERLIES / LOSS OF VISION DRA BRIL / WEARING SPECTICLES KONTAKLENSE / CONTACT LENSES GEHOOR / HEARING GEHOORVERLIES / LOSS OF HEARING GEBRUIK GEHOORAPPARAAT / USES HEARING AID BLOEDSOMLOOPSTELSEL / CIRCULATORY SYSTEM BLOEDDRUK / BLOOD PRESSURE. POLS / PULSE PERIFERE SIRKULASIE / PERIPHERAL CIRCULATION SIANOSE / CYANOSIS

ASEMHALINGSTELSEL / RESPIRATORY SYSTEM SPOED / RATE LUGWEG / AIR FLOW GESKIEDENIS VAN WERK / OMSTANDIGHEDE MET LONG RISIKO`S / HISTORY OF EMPLOYMENT/ CIRCUMSTANCES POSING LUNG FUNCTION RISKS MEDIKASIE / MEDICATION SKELET-SPIER STELSEL / SKELETAL-MUSCULAR SYSTEM GANG / GAIT ARTRITIS / ARTHIRITIS SPASTISITEIT / SPASTICITY GEBREKLIKHEID / DEFORMATIES STAPTOESTEL ROLSTOEL-BEDGEBONDE / WALKING AID-WHEEL CHAIR-BED RIDDEN

GESLAG-URINE STELSEL / GENITO-URINARY SYSTEM ROETINE URINE TOETS / ROUTINE URINE TEST INKONTINENSIE / INCONTINENCE SENUWEESTELSEL / NERVOUS SYSTEM TREMORE / TREMORS DUISELIGHEID / VERTIGO HOOFPYN / HEADACHES EPILEPSIE / EPILEPSY PERIFERE NEUROPATIE / PERIPHERAL NEUROPATHY KLIERE / GLANDS BORSTE / BREASTS SKILDKLIER / THYROID GLAND PANKREAS (DIABETES) / PANCREAS (DIABETES). PROSTAAT/PROSTATE GLAND MEDIKASIE / MEDICATION KLAGTES / COMPLIANTS GEESTESTOESTAND / MENTAL STATE

WAAKSAAMHEID / ALERTNESS ORIëNTASIE / ORIENTATION GEHEUE / MEMORY EMOSIES / EMOTIONS GESKIEDENIS VAN GEESTESONGESTELDHEID / HISTORY OF MENTAL ILLNESS SLAAPPATROON / SLEEPING PATTERN MEDIKASIE / MEDICATION VEL / SKIN LETSELS / LESIONS UITSLAG / RASHES LITTEKENS / SCARS VOETE / FEET EELTE / CALLOUSES LIDDORINGS / CORNS EDEEM / OEDEMA

ANDER / OTHER ROKER / SMOKER... ALKOHOL GEBRUIK /ALCOHOL USE VORIGE BEHANDELING VIR ALKOHOLISME / PREVIOUS TREATMENT FOR ALCOHOLISM LAKSEERMIDDELS/LAXATIVES DWELMMIDDEL MEDIKASIE/DRUGPATENTED MEDICATION ALLERGIEë/ALLERGIES OPERASIES/OPERATIONS PROSTESE/PROSTHETIC AID VORIGE BEENBREUKE/PREVIOUS BONE FRACTURES GINEKOLOGIESE OBSTETRIESE GESKIEDENIS / GYNAECOLOGICAL OBSTETRICAL HISTORY... HUIDIGE DIAGNOSE/CURRENT DIAGNOSIS SAL HUIDIGE TOESTAND VERBETER/IS PRESENT CONDITION LIKELY TO IMPROVE

VOLLE NAAM VAN PRAKTISYN/ FULL NAME OF MEDICAL PRACTISIONER ADRES/ADDRESS.. HANDTEKENING/SIGNATURE DATUM/DATE SERTIFIKAAT DEUR INWONER / NAASBESTAANDE EK / ONS DIE ONDERGETEKENDE/S BEVESTIG HIERMEE DIE VOLGENDE: 1 DIE INHOUD VAN HIERDIE MEDIESE VERSLAG IS KORREK EN VOLLEDIG; 2 EK/ONS BEVESTIG DAT GEEN VORIGE OF HUIDIGE MEDIESE SIEKTE/TOESTAND VAN DIE INWONER VERSWYG IS NIE; 3 EK/ONS VERSTAAN DAT `N VERSWYGDE VORIGE OF HUIDIGE MEDIESE SIEKTE/TOESTAND TOT GEVOLG KAN Hê DAT MY VERBLYF BY SOLHEIM TUISTE VIR BEJAARDES ONVER- WYLD BEEïNDIG KAN WORD. GETEKEN TE. OP DIE DAG VAN

INWONER / NAASBESTAANDE NMS INWONER CERTIFICATE BY RESIDENT / NEXT OF KIN I / WE THE UNDERSIGNED HERBY CONFIRM THE FOLLOWING: 1 THE CONTENT OF THIS MEDICAL REPORT IS BOTH CORRECT AND A FULL REPORT; 2 I / WE CONFIRM THAT I / WE HAVE NOT OMITTED TO DISCLOSE ANY PREVIOUS OR CURRENT MEDICAL ILLNESS / CONDITION OF THE RESIDENT; 3 I / WE UNDERSTAND THAN FAILURE TO DISCLOSE A PREVIOUS OR CURRENT MEDICAL ILLNESS / CONDITION COULD LEAD TO IMMEDIATE CANCELLATION OF MY RESIDENCE AT SOLHEIM TUISTE VIR BEJAARDES. SIGNED AT.. ON THIS THE.. DAY OF RESIDENT / NEXT OF KIN OBO RESIDENT

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