Preliminary Health Screening



PRELIMINARY HEALTH SCREENINGCase Name:Name: Last: FORMTEXT ?????First: FORMTEXT ?????M.I.: FORMTEXT ?????Admission Date: FORMTEXT ?????Date of Birth: FORMTEXT ????? FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Non-BinaryScreen Date: FORMTEXT ????? Case #: FORMTEXT ?????Section A: Identification (to be completed by local district or shelter staff within 24-hours of admission)Emergency Contact (other than head of household)Name:Address:Phone:Relationship to Resident: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Healthcare Provider or ClinicPrimary Care Doctor FORMTEXT ????? FORMTEXT ?????Name of person providing historical information on this individual, if other than individual:Relationship FORMTEXT ????? FORMTEXT ?????Section B: Medical HistoryCheck each item below as it applies to this individual.YesNoN/ACurrent or historyIf yes, please specify or describe FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Less than 18-years old(fill out section C also) FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Evidence of a contagious condition FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cancer or immune system diseases FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mental health conditions or concerns FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Epilepsy, seizures or fainting spells FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Alcohol or substance abuse FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Surgery or hospitalization within the last six months FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Open or draining wounds FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX High blood pressure or diabetes FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lung problems such as asthma, chronic bronchitis or COPD FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Receiving treatment for a heart condition FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Allergies to medication, foods or materials FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Speech, hearing or visual impairment FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Dental problems or concerns FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Is the individual pregnantExpected delivery date: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX If yes, does the individual receive prenatal care FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Currently taking any prescription medications (list) FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Currently taking any controlled substances FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Receiving treatment for any other medical conditions FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Can the individual ambulate without assistance FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Does the individual appear to be medically healthy FORMTEXT ?????Section C: Child ImmunizationsYesNoN/ACurrent or historyIf yes, please specify or describe FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Are child’s immunizations up to date? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX If no, is there an appointment made with the pediatrician to update them?Appt date: FORMTEXT ?????Does the resident currently need any assistance in finding a doctor or making any medical appointments? FORMTEXT ?????Individual’s Signature: FORMTEXT ?????Date: FORMTEXT ????? FORMCHECKBOX I am signing on behalf of my childIndividual’s Signature: FORMTEXT ?????Date: FORMTEXT ?????Title: FORMTEXT ?????In case of transfer: This form is good for 1 year and should transfer with the individual ................
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