History provided by ***Self/Spouse/Child/Other***
Language: ***English/Spanish/Other***
Marital History: ***Married/Widowed/Divorced/Single***
Resident lives ***at home/at apartment/at skilled nursing home/at assisted living/with family member/at adult foster care***.
Past Medical/Surgical History: ***
Mental Health
***Geriatric Depression Score***
***Mini Mental Status Exam***
Number of Previous Admissions: ***
Current Medications: ***Name, dose, frequency, dx***
Review all medications for important interactions: ***
Special Dietary needs:
a) Loss of 10 pounds in last 6 months ***Yes/No***
b) Is referral to dietician indicated ***Yes/No***
Special Equipment or Therapy: ***
13. Sensory/Expressive Impairment:
a) Hearing (last hearing test) ***
b) Visual (last eye exam) ***
Bladder: ***Continent/Incontinent***
Bowel: ***Continent/Incontinent***
Activities of Daily Living: Needs Help
a) Bathing ***Yes/No***
b) Transferring ***Yes/No***
c) Dressing ***Yes/No***
d) Cooking ***Yes/No***
e) Shopping ***Yes/No***
f) Driving ***Yes/No***
g) Taking medications ***Yes/No***
h) Reaching light switches ***Yes/No***
i) Home security ***Yes/No***
j) Ability to use phone ***Yes/No***
k) Housekeeping ***Yes/No***
l) Laundry ***Yes/No***
m) Home repairs ***Yes/No***
n) Money management (finances) ***Yes/No***
o) Ability to respond in emergency ***Yes/No***
Someone in the household able to assist ***Yes/No***
Mobility: Balance/Mobility
Use of device: Yes or No
Get up & go test ***Positive/Negative***
(Pos > 16 seconds) (Rise from chair, walk 10 feet, turns and returns to chair to sit)
History of falls ***Yes/No***
Skin Integrity:
Skin breakdown: ***Yes/No***
Wound care/education needed ***Yes/No***
Sleep Disorders: Yes or No
Substance Abuse:
ETOH ***Yes/No***
Drugs ***Yes/No***
Overuse Narcotics ***Yes/No***
Tobacco ***Yes/No***
Immunizations:
Tetanus: ***Yes/No***
Influenza ***Yes/No***
Pneumococcal ***Yes/No***
Educational/Vocational History: ***
Social Supports: ***
Living Will: ***Yes/No***
Power of Attorney for Health Care: ***Yes/No***
Power of Attorney for Finances: ***Yes/No***
Code Status: ***Full Code/DNR-DNI/DNR-DNI (hospitalize as necessary)/DNR-DNI (comfort care)/Hospice
Spiritual Needs:
Referral Needs: OT ***Yes/No***
PT ***Yes/No***
Speech ***Yes/No***
Social Services ***Yes/No***
Home Health Care ***Yes/No***
Plan of Care/Recommendations: ***
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{ 1 comment… read it below or add one }
You have done a great job in being comprehensive here! To make it more meaningful to me, I amended the following:
1) Asking about chewing and swallowing–because of dental and denture issues as well as presbyesophagus .
2) Home modifications for safety, i.e. grab bars, shower bench, hand rails, raised toilet seat, etc
3) General home assessment to Reduce Risk of falls (typically done by home P.T. on first eval.)
Thanks
4)Immunizations: dT instead of just T as diphtheria is on the rise
5) Smoking (now) yes or no. Number of pack years_____
6)Own a “Reacher/Grabber” device?
6) Pneumococcal: date or year
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