REFERREDBY:PHONE:FAX:PROJECTOPEN HAND

730PolkStreet,SanFrancisco,CA94109 415/447-2326 Fax:415/447-24921921SanPabloAvenue,Oakland,CA94612 510/622-0221 Fax:510/452-1061

ApplicationforServices (6 month duration; subject to eligibility)

Iauthorize my medicalproviders andreferring partytoreleaseinformation about mymedicalcondition toProjectOpenHand forpurposes ofverifying
myeligibility. I also authorize Project Open Hand to discuss the terms of my eligibility and/or services with my medical providers and referring party.

NOPRIMARYDIAGNOSIS

HIV+/AIDS

Cancer,activediagnosis

Type:______Stage:______

Date of most recent diagnosis:______

Active Treatments: (circle those that apply)

- Radiation therapy - Chemotherapy

- Hormonetherapy - Not receiving treatment

 Diabetes

Type1 or Type 2 (circleone)
HbA1c: ______Date: ______

End stage Renal Disease (ESRD)
Creatinine:______BUN:______Date:______

End Stage Liver Disease (ESLD)

Cardiovascular disease (circle those that apply)
- Congestive Heart Failure (CHF) - NYHA Class:______
- Coronary Artery Disease
Total cholesterol:______HDL / LDL:______/ ______
Triglycerides: ______Date: ______

Chronic Obstructive Pulmonary Disease (COPD)
Stage:______FEV1:______Date:______

Autoimmune disease(e.g.Lupus)

Hepatitis B, chronic or HepatitisC (circle those that apply)

SeriousNeurologicCondition (circle those that apply)

- Stroke- Parkinson’s
- Multiple Sclerosis- ALS (Lou Gehrig’s disease)

Trauma/major surgery, within 30 daysof discharge (6 week service)

Type:______Discharge date:______

NOSYMPTOMS

Chronic (>30 days), inhibits normal daily functioning:(circlethosethatapply) - Intractablediarrhea - Nausea - Vomiting

Unintentionalweight lossofmorethan5%ofbaselinebody weightin1monthor10%in6months

Inabilitytogainweightifunderweight (BMI <18.5)

Oralconditionspreventingadequatenutritionalintake

Muscleweaknessinoneormoreofthefollowing areas:hands, arms orlegs, orthemusclesofspeechorbreathing

Difficulty standing and/or ambulation due to: (circle those that apply) - Twitching(fasciculation) - Numbness - Tingling - Cramping of muscles

Edema, or other severe swelling in ankles or feet

Difficulty swallowing (dysphagia)

Fatigue: (circle one) - Mild - Moderate -Severe

Shortnessofbreathatrest: (circle one) - Mild - Moderate -Severe

REFERREDBY:PHONE:FAX:PROJECTOPEN HAND

730PolkStreet,SanFrancisco,CA94109 415/447-2326 Fax:415/447-24921921SanPabloAvenue,Oakland,CA94612 510/622-0221 Fax:510/452-1061

ApplicationforServices (6 month duration; subject to eligibility)

PatientName:______

Dementia

Hospice or palliative care

Homeless or marginally housed

Substance use

Describe:______

Mentalillness

DSM V diagnosis: ______

Cognitive deficit

Describe: ______

Developmentaldisability

Describe: ______

PATIENTISABLETO PICKUP MEALSorPATIENTHAS SUPPORTPERSONTO PICKUP MEALS

Bedbound

Unlikelyabletostandformorethan15minutesata time

Unlikelyabletowalkmorethan50 feetata time

Unlikelyabletocarrya weight ofmorethan15lbs.

Likelytoneed physicalor otherassistanceinleavinghome

Requires24hrs/dayoxygentotreatlungorheartdisease

Requiressomeonetohelppatient prepare/cook food

Leavinghomemaycreatesafetyriskorhardship

Consult with patient’s existing dietitian: Name -______Phone -______

Refer patient to Project Open Handregistered dietitian:(list labs, relevant medical history, medications, surgeries, or other information)