Primary Care Physician name, address, phone (into personal ...
Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Date of Admission: FORMTEXT ?????Organization/Program Name: FORMTEXT ?????DOB: FORMTEXT ?????Gender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX TransgenderVital Signs:Height: FORMTEXT ????? Weight: FORMTEXT ????? Blood Pressure: FORMTEXT ????? BMI: FORMTEXT ????? Respiratory Rate: FORMTEXT ????? Pulse: FORMTEXT ????? Temperature: FORMTEXT ?????Allergies: FORMCHECKBOX No Known Allergies Medication Allergies and Medication Sensitivities (including OTC, herbal): FORMTEXT ?????Food: FORMTEXT ????? Environmental: FORMTEXT ????? Recent Assessments/Examinations: Most Recent BloodworkDateResultsPhysicianMedication Level FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Blood Chemistry FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Fasting Blood Sugar (Hb-A1C) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Bone Density FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Complete Blood Count with Differential FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Lipid Panel/Cholesterol Level FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Thyroid Level FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Hep A FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Hep B FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Hep C FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????STD Testing FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????HIV Assay FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Prostate Screen - PSA FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????For OTP only-Liver function profile: SGOT: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SGPT: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Sickle cell screening: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Most Recent ScreeningDateResultsPhysicianLast Physical Examination FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TB Screen – PPD FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Chest X Ray FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????EKG FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Urinalysis/Routine and Microscopics Drug Screen Etc. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Genital Exam / Pap Smear/ Pregnancy Test FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Person’s Name: FORMTEXT ?????Record #: FORMTEXT ????? Mammogram FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Colonoscopy FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Breathalyzer FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Others As Indicated: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Medical Hospitalizations: FORMCHECKBOX None ReportedHospital:Date of ServiceReason (Medical Procedure, Acute Illness, Birth of Child Etc.) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Unresolved Surgical Care Needs FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, explain: FORMTEXT ?????Does the person use complimentary health approaches (e.g. natural products, mind-body practices, yoga)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please describe: FORMTEXT ?????Does the person wish to consider using complimentary health approaches and want help finding a provider? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA If yes, please describe: FORMTEXT ?????Medical HistoryCardiovascular Illness: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Hypertension FORMCHECKBOX History of heart attack FORMCHECKBOX Coronary Artery Disease? FORMCHECKBOX Peripheral Artery Disease FORMCHECKBOX Congestive Heart Failure FORMCHECKBOX Heart Murmur FORMCHECKBOX CVA (Stroke) FORMCHECKBOX Chest pain: Duration: FORMTEXT ????? Average Intensity (1-10): FORMTEXT ????? Frequency: FORMTEXT ????? FORMCHECKBOX Edema: Location: FORMTEXT ????? FORMCHECKBOX Non-Pitting Pitting: FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX Other: FORMTEXT ?????Respiratory System: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Chronic Obstructive Pulmonary Disease FORMCHECKBOX Emphysema FORMCHECKBOX Asthma FORMCHECKBOX Sleep Apnea FORMCHECKBOX Tuberculosis: FORMCHECKBOX Active FORMCHECKBOX History of / FORMCHECKBOX Treated or FORMCHECKBOX Untreated FORMCHECKBOX Oxygen dependent: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX C pap machine FORMCHECKBOX Bi-pap machine FORMCHECKBOX Shortness of breath at rest FORMCHECKBOX Shortness of breath minimal effort Person’s Name: FORMTEXT ?????Record #: FORMTEXT ????? Endrocrine System: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Hyperthyroidism FORMCHECKBOX Hypothyroidism FORMCHECKBOX Metabolic Syndrome FORMCHECKBOX Pituitary: FORMTEXT ????? FORMCHECKBOX Pineal: FORMTEXT ?????Diabetes FORMCHECKBOX Family History of diabetes Diabetes diagnosis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Type 1 FORMCHECKBOX Type 2 FORMCHECKBOX Non-insulin dependent diabetes mellitus FORMCHECKBOX Insulin dependent diabetes mellitus (complete section on Injection Administration) FORMCHECKBOX Oral agent FORMCHECKBOX Diet: FORMTEXT ????? FORMCHECKBOX Daily blood sugars: FORMCHECKBOX Yes FORMCHECKBOX NoAble to manage diabetic care on own: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Sometimes FORMCHECKBOX Unknown FORMCHECKBOX Other: FORMTEXT ?????Neurological Disorder: ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Migraines FORMCHECKBOX Headaches FORMCHECKBOX Dizziness FORMCHECKBOX Seizures- Type: FORMTEXT ????? Frequency: FORMTEXT ????? FORMCHECKBOX Epilepsy FORMCHECKBOX Syncope FORMCHECKBOX Tremors FORMCHECKBOX Delirium Tremens FORMCHECKBOX Decreased sensitivity FORMCHECKBOX ?History of Head Trauma FORMCHECKBOX ?History of?Stroke/TIA FORMCHECKBOX History of?loss of consciousness FORMCHECKBOX Weakness FORMCHECKBOX Paralysis FORMCHECKBOX Somnolent FORMCHECKBOX Distractible FORMCHECKBOX Dementia FORMCHECKBOX Alzheimer’s FORMCHECKBOX Eastern Equine Encephalitis (EEE) FORMCHECKBOX Requires prompting under new situations/conditions FORMCHECKBOX Other: FORMTEXT ?????Movement Disorder: ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Tardive Dyskinesia FORMCHECKBOX Dystonia FORMCHECKBOX Akathisia FORMCHECKBOX Parkinsonism FORMCHECKBOX Extra Pyramidal Symptoms FORMCHECKBOX Multiple Sclerosis FORMCHECKBOX Cerebral Palsy FORMCHECKBOX Muscular Dystrophy FORMCHECKBOX Other: FORMTEXT ?????Immune System Disorder: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX HIV FORMCHECKBOX AIDS FORMCHECKBOX Lupus FORMCHECKBOX Chronic Fatigue Syndrome Bacterial/Viral Infections: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Sexually Transmitted Infections - (Specify): FORMTEXT ????? FORMCHECKBOX MRSA FORMCHECKBOX VRE FORMCHECKBOX Hepatitis: FORMCHECKBOX A FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX Lyme Disease FORMCHECKBOX Meningitis Visual Impairment: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Glaucoma FORMCHECKBOX Cataracts FORMCHECKBOX Blurred Vision FORMCHECKBOX Glasses FORMCHECKBOX Contacts FORMCHECKBOX Itching FORMCHECKBOX Inflammation FORMCHECKBOX Abnormal Pupils FORMCHECKBOX Blind FORMCHECKBOX Legally Blind FORMCHECKBOX Other: FORMTEXT ?????Date of last eye exam: FORMTEXT ?????Auditory Impairment: ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Chronic ear infections FORMCHECKBOX Hard of hearing: FORMCHECKBOX Right FORMCHECKBOX Left FORMCHECKBOX Deaf: FORMCHECKBOX Right FORMCHECKBOX Left FORMCHECKBOX Hearing Aid(s) FORMCHECKBOX Tinnitus FORMCHECKBOX VertigoDate of last hearing exam: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? Person’s Name: FORMTEXT ?????Record #: FORMTEXT ????? Digestive/Urinary Conditions: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Incontinence: FORMCHECKBOX Fecal FORMCHECKBOX Urinary: FORMCHECKBOX Stress Incontinence FORMCHECKBOX Overflow Incontinence FORMCHECKBOX Diarrhea FORMCHECKBOX Constipation FORMCHECKBOX Urinary Infection FORMCHECKBOX Prostate Disorder FORMCHECKBOX Colitis FORMCHECKBOX Crohn’s Disease FORMCHECKBOX Ostomy FORMCHECKBOX Nausea FORMCHECKBOX VomitingDental Conditions: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Own teeth, condition: FORMTEXT ????? FORMCHECKBOX No Teeth/Missing Teeth FORMCHECKBOX Dentures: FORMCHECKBOX Upper FORMCHECKBOX Full FORMCHECKBOX Partial: fit: FORMTEXT ????? FORMCHECKBOX Lower FORMCHECKBOX Full FORMCHECKBOX Partial: fit: FORMTEXT ????? Oral Mucosa: FORMCHECKBOX Moist FORMCHECKBOX Dry FORMCHECKBOX Lesions FORMCHECKBOX Other: FORMTEXT ?????Reproductive Health:Sexually Active FORMCHECKBOX Yes FORMCHECKBOX NoPregnant FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA If pregnant, include information on pre-natal care: FORMTEXT ?????Is Woman breastfeeding? FORMCHECKBOX Yes FORMCHECKBOX NoBirth control method in use: FORMCHECKBOX Yes FORMCHECKBOX No Type: FORMTEXT ?????Sex education needed: FORMCHECKBOX Yes FORMCHECKBOX NoAdvanced Directives in place: FORMCHECKBOX Health Care Proxy FORMCHECKBOX DNR/Comfort Care Orders FORMCHECKBOX Other Advanced Directives: FORMTEXT ????? Pain Assessment Screening: On a scale of Zero to Ten, please rate your level of pain today: FORMCHECKBOX 0 FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10No PainMild PainModerate PainSevere PainWorst Possible PainDoes pain currently interfere with your daily activities? FORMCHECKBOX Yes FORMCHECKBOX No If yes how much?: FORMCHECKBOX Some of the time FORMCHECKBOX Most of the Time FORMCHECKBOX All of the Time Ambulation: FORMCHECKBOX Independent FORMCHECKBOX Steady FORMCHECKBOX Gait disturbance FORMCHECKBOX History of falls FORMCHECKBOX Requires assist/supervision FORMCHECKBOX Adaptive equipment: Specify FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Dietary/Nutrition: FORMCHECKBOX Appropriate BMI FORMCHECKBOX Overweight/Obese FORMCHECKBOX Underweight FORMCHECKBOX Recent Weight Loss/Gain: FORMTEXT ????? FORMCHECKBOX Swallowing/Feeding Difficulties FORMCHECKBOX Special diet/Fluid restriction: FORMTEXT ?????Diseases of the Liver: FORMCHECKBOX None Reported FORMCHECKBOX Acute fatty liver FORMCHECKBOX CirrhosisDermatologic Conditions: FORMCHECKBOX None Reported FORMCHECKBOX Acne FORMCHECKBOX Eczema FORMCHECKBOX Seborrhea FORMCHECKBOX Psoriasis FORMCHECKBOX Evidence of needle use FORMCHECKBOX Other FORMTEXT ????? Person’s Name: FORMTEXT ?????Record #: FORMTEXT ????? Cancer: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what type of cancer: FORMTEXT ????? Treatments received: FORMTEXT ????? Currently in remission: FORMCHECKBOX Yes FORMCHECKBOX No, if yes, for how long: FORMTEXT ????? Years / FORMTEXT ????? MonthsBone and Joint Conditions: FORMCHECKBOX None Reported FORMCHECKBOX Arthritis FORMCHECKBOX Osteoporosis FORMCHECKBOX Fibromyalgia Have these conditions led to: FORMCHECKBOX Decreased Mobility FORMCHECKBOX Uses Wheelchair FORMCHECKBOX Uses other Assistive DevicesComments: FORMTEXT ?????For Opiate Treatment Programs:Attach completed Physical Examination by a qualified health professional including:Physician’s overall impression of the clientJustification that approved opioid/narcotic being dispensed is not contraindicated with the client’s other medications reported Results of Microscopic urinalysis including analysis of glucose and proteinComments, Recommendations or Referrals by Medical Reviewer: FORMCHECKBOX No Referral NeededCheck Referral(s) Needed and Specify Action(s) FORMCHECKBOX Primary Healthcare Provider: FORMTEXT ????? FORMCHECKBOX Healthcare Agency: FORMTEXT ????? FORMCHECKBOX Specialty Care: FORMTEXT ????? FORMCHECKBOX Other - specify: FORMTEXT ????? Recommendations shared with the Person Served? FORMCHECKBOX No FORMCHECKBOX Yes If Yes, the Person’s Served Response: FORMTEXT ?????If No, how will recommendations be shared with the Person Served?: FORMTEXT ????? Person’s Signature (Optional, if clinically appropriate) FORMTEXT ?????Date: FORMTEXT ?????Parent/Guardian Signature (If appropriate): FORMTEXT ?????Date: FORMTEXT ?????Clinician/Provider - Print Name/Credential: FORMTEXT ?????Date: FORMTEXT ?????Supervisor - Print Name/Credential (if needed): FORMTEXT ?????Date: FORMTEXT ?????Clinician/Provider Signature: FORMTEXT ?????Date: FORMTEXT ?????Supervisor Signature (if needed): FORMTEXT ?????Date: FORMTEXT ?????Psychiatrist/MD/DO (If required): FORMTEXT ?????Date: FORMTEXT ????? ................
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