Kit Clark Senior Services Medical Pre-Admission Record

KIT CLARK SENIOR SERVICES MEDICAL PRE-ADMISSION RECORD

Dear Doctor,

The patient listed below is applying for admission to our Adult Day Health Program. Please fill out this medical form as completely as possible and return it to us at:

Kit Clark Senior Services Adult Day Health at Fields Corner, 1500 Dorchester Avenue, Dorchester, MA 02122

fax: 617-288-5991; phone: 617-533-9197

Applicant’s Name: ______D.O.B.______

Address:______Phone:______

Please attach a copy of the most recent Physical Examination and/or latest Hospital Discharge Summary if in

the last 3 months.

Date of last office visit/exam: (musthave been within three months)

The patient must demonstrate negative TB status either through a PPD or a TB history or risk assessment (without symptoms) within the last three months or a chest x-ray within the past three years:

Date& results: PPD Chest x-ray

If positive, does the patient show signs or symptoms of active TB?

Allergies: Medication: ______Food:______

Diagnoses: Date of Onset Prescribed treatment: Please include meds, dressings,

(if known) topicals, oxygen, at home IV’s, etc.

Flu vac Pneumovax: Hep B vac: I II III

Mammogram Pap or Testicular screening

Therapies ordered: PT_____ OT Speech _____ Med Social Work _____ HHA____

Homemaker G-Tube feedings:______

Current wt: IBW BP Desired BP range

Last U/A Last HCT Last PTT Last alb.

Last Blood sugar: date & results Desired BS range

FUNCTIONAL STATUS ASSESSMENT

1. Mobility: Amb: ______Cane: ______Walker: ______W/C: ______

2. Bathing & Dressing: Indep.: ______Needs Supervision: ______Needs Assistance:______

3. Toileting: Indep.: ______Needs Supervision: ______Needs assist.: ______Incont. Urine: ______Incont. Stool: ______Brief /Pad: ______

4. Sensory: Vision: Good: _____ Fair: _____ Poor: _____ Legally blind: R: ____ L: ______Hearing: Good: ______Fair: ______Poor: _____ Deaf: R: _____ L: _____ Speech:______

5. Mental & Behavioral:

Memory intact: ______Cooperative: ______Fully alert & appropriate:______

Behavioral Issues (Agitation? Withdrawn? Aggression?): ______

______

Disturbed sleep: ______Wandering behavior: ______

Other:

Speech/language deficits:

Mobility/physical limitations:

Assistive devices used:

Level of cognitive functioning and your recommendation for management:

Significant Medical History: surgeries, fractures, hospitalizations—when, why, etc.

Your recommendations and concerns re health management:

Diet order: Food is prepared with some salt and considered low fat.

(Please check) House: ____ Diabetic: ______Low Fat:______Low Sodium:_____ Other:______

Exercise Programs Held at Kit Clark Adult Day Health:

* Daily low impact 60 min exercise program

* Low impact weight training

I give my patient permission to participate in the KC exercise program: YES NO

Exercise Restrictions: ______

I recommend this applicant attend an Adult Day Health program for assistance with day-to-day health management. (Please check)

MD Signature Date Full Address

Print Name Telephone Fax

MD Responsible for cont. care (if different) Full Address