F5 Medical Form for Adults - New Jersey
[Pages:2]Form #5: page 1 of 2
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES - DIVISION OF DEVELOPMENTAL DISABILITIES
Medical Form for Adults
Name: ____________________________ Age: ______ DOB: ________ { } Male { } Female Health Insurance #: _____________________ SS#: ______________ Exam Date: _________
A. HISTORY:
1) Indicate any present and past medical condition (include communicable disease history):
2) Previous hospitalizations/surgery:
3) Immunizations: Adult Diphtheria/Tetanus-Date: _________ (Document date of last booster OR administer if more than 10 years ago.) Hepatitis B Immunization (if given) Date: [1] _________ [2] _________ [3] _________
B. LABORATORY TESTS:
1) Mantoux Test yearly if non-reactor or chest x-ray if indicated. Past or current results must be documented: Results: ______________________________________________ Date: _____________ Tine test is not acceptable. Positive Mantoux reactor should never be retested.
2) Hepatitis B Profile: Initial (repeat at physician's discretion). Results: ______________________________________________ Date: _____________ (Past or current results must be documented).
3) Lead Poisoning: Blood Lead Level is required: a. For Individuals with known Pica behavior, test annually, or according to guidelines for elevated lead levels b. Prior to discharge from development center (within 3 months of discharge). c. For all new admissions to Divisional residential services (within 3 months prior to admission or within 10 days after admission). Blood Level: ________________________________________ Date: ___________
4) SMAC, initial (repeat at physician's discretion): 5) Complete Blood Count, initial (repeat at physician's discretion): 6) Urinalysis, initial (repeat at physician's discretion): 7) Serology, initial (repeat at physician's discretion): 8) Pap Smear (follow American Cancer Society guidelines): 9) EKG ? initial at age 40 (repeat at physician's discretion):
C. OTHER MEDICAL CONDITIONS/NEEDS:
1) Seizures: { } Yes { } No Frequency & Type, if known:
2) Special Dietary Needs: { } Yes { } No (Attach Prescription):
3) Allergies, Sensitivities: (foods, drugs, others):
4) Mental Health Problems (Behavioral/Psychiatric Disorders):
DDD Day Program Manual 11/06
Forms: Form F5
Form #5: page 2 of 2
D. MEDICATION: Name: _________________ Dosage: ________ Frequency: _______ Indication:________ Name: _________________ Dosage: ________ Frequency: _______ Indication:________ Name: _________________ Dosage: ________ Frequency: _______ Indication:________ Name: _________________ Dosage: ________ Frequency: _______ Indication:________ Name: _________________ Dosage: ________ Frequency: _______ Indication:________
E. CLINICAL EXAMINATION: 1) Height: _____ Weight: _____ Temp.: _____ Pulse: _____ B.P.: ______ 2) Sensory (Indicate any impairment and extent): Eyes: Vision (Glasses, etc.): Hearing: (Aids, etc.): 3) ENT: 4) Teeth & Gums: 5) Neck: 6) Breast (Follow American Cancer Society Guidelines for Mammography):
7) Lymphatic System: 8) Respiratory System: 9) Cardiovascular System: 10) Gastrointestinal System (Stool for occult blood after age 50): 11) Genitourinary System: 12) Prostate: 13) Muscular System: 14) Skeletal System: 15) Neurological System: ADDITIONAL INFORMATION/RECOMMENDATIONS: (Please indicate if there are limitations or restrictions regarding physical activities)
PLEASE ISSUE PRESCRIPTIONS FOR MEDICATION, DIET, ADAPTIVE EQUIPMENT, PROCEDURES AND THERAPIES. (Please Print or Type CLEARLY) Physician's Name: ________________________________________ Date: __________________ Address: ______________________________________________ Phone #: __________________ Physician's Signature: ________________________________________________________________
PLEASE RETURN COMPLETED FORM TO:
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
THANK YOU FOR YOUR COOPERATION
DDD Day Program Manual 11/06
Forms: Form F5
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