The Lorelton Assisted Living MEDICAL INFORMATION REPORT (To be completed by Applicant s Physician) has expressed interest in residing at The Lorelton. A requirement for admission is the completion of this medical report. Thank you for your cooperation and assistance. If you have any questions, please call the Director of Nursing at The Lorelton at (302) 573-3580. Please fax completed form to 302.573.3590. I hereby authorize the release of all requested medical information to The Lorelton. Signature of Applicant Date Name of Applicant: Age Birth Date Sex I have known this applicant previously. YES NO Number of years 1
PAST MEDICAL HISTORY Check the following conditions applicant has been treated for or is still being treated for. Allergy Cancer Typhoid Fever COPD Ulcer Rheumatic Heart Disease Asthma Hernia CAD Bronchitis Arthritis PVD Emphysema Hypertension Prostate Enlargement Tuberculosis Diabetes Glaucoma Paralysis Cataracts Seizure Disorder Kidney Disease Alcohol Use Parkinson s Disease Hepatitis Type Stroke Smoker Other (Specify) Further details of positive responses: PAST SURGICAL HISTORY: 2
PRESENT SYMPTOMS: Pain Edema Weight Loss Headache Dyspnea Obesity Angina Palpitation Hemmorhage Tinnitus Numbness Melena Vertigo Tingling Persistent Cough Weakness Parasthesia Nocturia; frequency Fatigue Claudication Bowel Incontinence Tremors Spasms Retention; Incontinence (Bladder) Any recent change in bowel pattern: Other symptoms: Further details, severity, duration, recurrences, etc.: REVIEW OF SYSTEMS: Indicate good, fair, or poor. Explain if fair or poor. Note: If item is checked, the condition will be assumed normal. Head Eyes Throat Heart Ears Nose Skin Lung Digestive Mental Extremities 3
Pertinent Physical Findings: COGNITIVE STATUS: (Check where applicable) Degree of Senility: None Mild Moderate Severe Explain: Memory Loss: None Mild Moderate Severe Explain: History of wandering or disruptive behavior YES NO Explain: History of psychotic or emotional problems YES NO (including nervous disorders) Explain: Has applicant ever required treatment for YES NO alcoholism or drug dependency? Explain: Evidence of infection or contagious disease YES NO Explain: 4
MANDATORY FOR ADMISSION: Date of chest X-ray within last 12 months: Mantoux 1 st Step Test Date: Result: Result: Date of last influenza vaccine: Date of pneumonia vaccine: Date of last physical: Summary of Diagnosis: *Immunization Record MUST accompany this form for admission. In my opinion, the above patient requires the following assistance: None Dressing Psychological Assistance Ambulation Housekeeping Skin/Wound Care Meal Preparation Bathing Personal Hygiene Toileting Transferring Medication Administration Monthly Labs Yearly Labs Pacemaker Checks Yearly Labs Blood Pressure Continence Management DNR Blood Glucose Monitoring Other (explain): PHYSICIAN S NAME (Please Print) ADDRESS PHONE NUMBER DATE PHYSICIAN S SIGNATURE 5
The Lorelton Assisted Living Move In Orders Resident s Name Date of Admission Allergies: Physician Physician Phone Physician Fax Primary Diagnosis: DNR DNR/DNH FULL CODE MEDICATION/TREATMENTS ORDERS SHOULD INCLUDE DIAGNOSIS. LOA/PASS Generic substitution allowed for medications. Specify which medications are to be dispensed As written. May Self administer Meds Yes No WELLNESS ORDERS 1 st Step PPD Results 2 nd Step PPD Results Annual Flu Vaccine Last Dose Pneumonia Vaccine Last Dose ACTIVITY Restricted activity. If yes, explain: DIETARY NEEDS Has Resident executed: Advance Directives? Yes No Physician Signature Evaluate/ treat as indicated PT OT SLP Date 6
) IMMUNIZATION RECORD IMMUNIZATION DATE SIGNATURE/TITLE LOCATION LOT RESULTS/REACTIONS NUMBER (Include Follow-up if Needed) OTHER IMMUNIZATIONS (Specify).u.:«: :~.~... '- -. -:. - _/_/_, - Comments: NAME Last First Middle Attending Physician Record No. Room/Bed IMMUNIZATION RECORD BRIGGS.
THE LORELTON Assisted Living PREFERRED INTENSITY OF MEDICAL CARE AND TREATMENT A copy of the current, valid and state approved advanced directive must beprovided. Resident name: Date: _ I have fully discussed my future options for medical care and treatment, with both my physician and The Lorelton community. I have been informed of the benefits and risks of such options, and the potential consequences, and I am fully aware of my right to determine the course of my future treatment. Having considered all of these factors, I hereby direct my caregivers to honor my intentions with respect to the following treatments, should the need arise, all of which have been explained to me: (Initial your Choices) Resuscitate (Full Code) Do Not Resuscitate (DNR) Hospitalize Do Not Hospitalize (DNH) Do Not Treat (DNT) (specify): _ Feeding Restrictions (specify): ---,. _ Organ Donation (specify): Autopsy Request (specify): Other (specify); _ I request that my caregivers accept this statement as expression of my right to accept/refuse medical treatment..i request that all palliative care measures be undertaken on my behalf. Ihereby release The Lorelton, and their respective affiliates, employees, officers, directors, agents, successors and assigns from any and all liability arising from, or related to compliance with the directives I now make. I also understand that I may change this directive at anytime by notifying The Lorelton. Resident/Surrogate: Date: _ Facility Representative: Date: _ Physician: Date: _ 1