Geriatrics
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Patient: [textarea cols=40 rows=1]
Sex: [checkbox name="sex" value="male|female"]
DOB: [textarea cols=10 rows=1]
Age: [textarea cols=5 rows=1]
Address: [textarea cols=60 rows=2]

ITEM ORDERED [textarea cols=20 rows=1]
[checkbox name="item" value="Power (motorized) wheelchair|Power operated vehicle (scooter)"]
Date of face-to-face examination: [textarea cols=10 rows=1]
Date of order: [textarea cols=10 rows=1]
Start date: [textarea cols=10 rows=1]
Length of need: 99 months

DIAGNOSES [textarea cols=20 rows=1]
[checkbox name="diagnosis" value="Alzheimer’s disease|Arthritis|Cerebral vascular disease|Congestive heart failure|COPD|Degenerative disc disease|Deconditioning|Degenerative joint disease|Diabetes|Diabetic neuropathy|Dialysis|Dizziness|Hemiplegia/hemiparesis|History of falls|Multiple sclerosis|Obesity|Osteoarthritis|Paraplegia/paresis|Parkinson’s disease|Renal failure|Rheumatoid arthritis|Traumatic brain injury|Wheelchair bound"]

USE
[checklist name="use" value="indoor|outdoor|quick maneuverability in tight spaces"]

OPTIONS
[checklist name="options" value="power seating system|alternate drive control interface|elevating leg rests"]

HISTORY [textarea cols=20 rows=1]
Historian: [checkbox name="historian" value="patient|family member/facility staff|complete history unobtainable d/t memory loss|complete history unobtainable d/t pain|complete history unobtainable d/t fatigue"]
Time condition(s) present: [textarea cols=20 rows=1]
Setting: [checkbox name="setting" value="living at home|resident at an assisted living facility"]
Maximum distance ambulated independently: [checkbox name="max" value="5 feet|10 feet|20 feet|50 feet"]
Falls: [checkbox name="falls" value="none|occasional|frequent|risk of falls"]
Pressure sores: [checkbox name="sores" value="present|none currently|history of pressure sores"]

AMBULATION
Cane: [checkbox name="cane" value="not using|unable to use d/t upper extremity weakness|unable to use d/t upper extremity pain|unable to use d/t lower extremity weakness|unable to use d/t dizziness"]
Walker: [checkbox name="walker" value="not using|limited use d/t fatigue|limited use d/t dizziness|uses with assistance|unable to use independently d/t upper extremity weakness|unable to use independently d/t upper extremity limited range of motion|unable to use independently d/t upper extremity pain with motion|unable to use independently d/t lower extremity weakness"]
Manual wheelchair:
[checkbox name="manual" value="wheeled by staff|unable to use independently d/t upper extremity weakness|unable to use independently d/t upper extremity pain with motion"]
Progression of ambulation difficulty over time: [checkbox name="progression" value="improving|deteriorating|unchanged"]

Able to use power operated vehicle (scooter): [checkbox name="scooter" value="yes|no|requires joy stick controller|poor trunk stability|requires adjustable height armrests|unable to safely operate|requires elevating leg rests|requires fully reclining back|insufficient home space for maneuverability"]

ACTIVITIES OF DAILY LIVING
Reports limited activities of daily living d/t: [checkbox name="adl_limit" value="upper extremity weakness|upper extremity spasticity|lower extremity weakness|lower extremity spasticity|poor standing balance|poor sitting balance|poor coordination|poor endurance evidenced by shortness of breath with exertion|oxygen use|frequent falls|dizziness"]

ADLs requiring assistance of staff:
[checklist name="ADL" value="getting out of bed|dressing|grooming|transfer between bed, chair, & mobility device|toileting|ambulating around facility|ambulating around apartment|feeding"]

PHYSICAL EXAM
Weight: [textarea cols=10 rows=1]
Height: [textarea cols=10 rows=1]
Resting pulse: [textarea cols=10 rows=1]
Exertional pulse: [textarea cols=10 rows=1]
Blood pressure: [textarea cols=20 rows=1]
Respirations: [textarea cols=10 rows=1]
Oxygen saturation: [textarea cols=10 rows=1]

Posture: [textarea cols=40 rows=1]
Tremor: [checkbox name="tremor" value="no|yes"]
Vision: [checkbox name="vision" value="wearing glasses|sufficient to read newspaper with glasses on"]
Hearing: [checkbox name="hearing" value="grossly intact to conversation|hard of hearing"]
Cognition: [checkbox name="cognition" value="A/O x3|able to answer questions without difficulty"]
Neck: [checkbox name="neck" value="normal exam|decreased ROM|pain with motion"]
UE: [textarea cols=40 rows=1][checkbox name="ue" value="normal exam|deformity|impaired strength|decreased range of motion|decreased sensation|contracture|dialysis shunt on left|dialysis shunt on right|edema on left|edema on right"]
LE: [textarea cols=40 rows=1][checkbox name="le" value="normal exam|deformity|impaired strength|decreased range of motion|decreased sensation|contracture|edema on left|edema on right"]
Trunk: [textarea cols=40 rows=1][checkbox name="trunk" value="normal exam|kyphosis|weakness|decreased range of motion"]
Sit to stand: [checkbox name="sittostand" value="without difficulty|with significant difficulty|unable to perform independently"]
Gait: [textarea cols=40 rows=1][checkbox name="gait" value="without difficulty|non-ambulatory|shuffling|ataxic|wide|max assist|mod assist|stops every few steps to rest|diaphoresis|tachycardia|tachypnea"]
Skin: [textarea cols=40 rows=1][checkbox name="skin" value="grossly intact|wounds"]

NARRATIVE
This is a [textarea cols=6 rows=1] yo patient with several health problems worsening gradually over the past year despite use of multiple medications. Can no longer perform independently the majority of ADLs without significant SOB and overall discomfort. Reports doorways and halls are wide enough for a scooter that will allow access to shower, toilet, sink and dining room. Possesses physical and mental abilities to safely operate a power mobility device. Willing and motivated to use a power mobility device.

CERTIFICATION
I certify that the information provided is a true and accurate representation of my patient’s current condition and that a major reason for the visit was a mobility examination. I hereby incorporate this document into my patient's medical record.
Patient:
Sex:
DOB:
Age:
Address:

ITEM ORDERED

Date of face-to-face examination:
Date of order:
Start date:
Length of need: 99 months

DIAGNOSES


USE


OPTIONS


HISTORY
Historian:
Time condition(s) present:
Setting:
Maximum distance ambulated independently:
Falls:
Pressure sores:

AMBULATION
Cane:
Walker:
Manual wheelchair:

Progression of ambulation difficulty over time:

Able to use power operated vehicle (scooter):

ACTIVITIES OF DAILY LIVING
Reports limited activities of daily living d/t:

ADLs requiring assistance of staff:


PHYSICAL EXAM
Weight:
Height:
Resting pulse:
Exertional pulse:
Blood pressure:
Respirations:
Oxygen saturation:

Posture:
Tremor:
Vision:
Hearing:
Cognition:
Neck:
UE:
LE:
Trunk:
Sit to stand:
Gait:
Skin:

NARRATIVE
This is a yo patient with several health problems worsening gradually over the past year despite use of multiple medications. Can no longer perform independently the majority of ADLs without significant SOB and overall discomfort. Reports doorways and halls are wide enough for a scooter that will allow access to shower, toilet, sink and dining room. Possesses physical and mental abilities to safely operate a power mobility device. Willing and motivated to use a power mobility device.

CERTIFICATION
I certify that the information provided is a true and accurate representation of my patient’s current condition and that a major reason for the visit was a mobility examination. I hereby incorporate this document into my patient's medical record.
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