Form 06HM006E (DDS-6) - Amazon S3
[Pages:2]*06HM006E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES
Health Status and Monthly Medication Review
Service recipient DDSD case manager
Provider
Review month
Year
Case number Phone
Medication changes
List changes in non-prescription and prescription medication made during review.
Unusual or abnormal physical signs or symptoms
Any unusual physical sign, symptom, or concern for service recipient noted during review? Yes No If yes, check any signs or symptoms exhibited or expressed by service recipient during review.
Appetite changes
Swallowing/ucpoughing pdroowbnlems
Urinary changes
u
Blood pressure changes
Respiratory problems/shallow
Visual disturbances
Body temperature
breathing ? blue or gray lips/nails
Weight changes
g
Change in bowel
Fatigue while eating
Nausea/vomiting
or bladder habits
Food/liquid leaking from
Mood changes
Confusion/disorientation
mouth/nose during meal
Pulse changes
Dizziness/unsteady
Difficulty chewing for extended
Rash/hives/itching
Drowsiness
period of time
Sleep problems
u
Fluid intake Headache Pain tolerance/verbalized
Food residue left in mouth after swallowing
Drool significantly
Slurred speech Other:
Cough, choke, or gag at meals
Signature
Date of review
Routing: Original ? home record Copy ? DDSD case manager within
Revised 5-15-2008
06HM006E (DDS-6)
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06HM006E (DDS-6)
Health Status and Monthly Medication Review two working days after completion
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OKDHS issued 00-00-00
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