ANNUAL PHYSICAL FORM

This form to be used for Annual Physicals Only

Client: ______Appointment Date: ______

Doctor/Location: ______Appointment Time: ______

Primary Diagnosis: ______Date of Birth: ______Staff Attending Appt: ______

Diet: ______Allergies: ______

Current Medications (including topical and PRN medications):

Medication/Treatment / Dose/Frequency/Route / Reason for Use

Current concerns: ______

______

*Above to be completed by Zumbro House staff*

*Below to be completed by the Physician or Health Care Professional*

Temp:______Pulse: ______Blood Pressure: ______Date of Tetanus Booster: ______

Height: ______Weight: ______

General Health: Excellent Good Fair Poor

  • This person is free from communicable diseases. Yes No
  • Is manual restraint if endangering self or others medically contraindicated? Yes No
  • Is the annual flu vaccine recommended? Yes No
  • May take supervised leaves with medication. Yes No
  • Are alcoholic beverages contraindicated? Yes No
  • This person may administer their own medications. Yes No
  • Zumbro House nurse has permission to make decisions about missed dosages. Yes No
  • MD notified of medication errors at nurse’s discretion. Yes No

Summary of examination and lab work completed:______

______

New Orders:______

______

______

______

Next Appointment: ______

Physician/P.A. Signature: ______Date: ______

Physician’s Printed Name: ______

Standing Orders for Over-the-Counter Medications

Name: ______Allergies: ______

The following may be given on a PRN (as needed) basis. Medications contraindicated will be noted by the physician. Equivalent generic or store brands may be used. Follow all instructions as listed. Chart medications administered on the Medication Sheet. Document the reason for giving the medication and the client's response to the medication in the Health Progress Notes.

Fever/Pain:

Notify nurse of a temperature above 100°F or of pain not relieved by medication.

Tylenol (Acetaminophen) - 500 mg. 2 tablets every 4 hours as needed for fever ordiscomfort. Do not crush. OR

Tylenol Elixir (Acetaminophen) - 2 Tablespoons (30 cc) every 4 hours as needed forfever or discomfort. Do not exceed 8 tablespoons in 24 hours.

OR

Ibuprofen - 200 mg. 2 tablets every 4hours as needed. Do not exceed 6 tablets in 24hours.

Cold/Cough:

Notify nurse of a temperature above 100°F or below 97.6°F. Notify nurse if client hasbeen exposed to strep infection or if client experiences persistent cough, earache,congestion, or skin rash. Notify nurse if client has chest pain. Inform nurse of anysymptom lasting more than 3 days.

Tylenol (Acetaminophen) - 500 mg. 2 tablets every 4 hours as needed for fever ordiscomfort. Do not crush. OR

Tylenol Elixir (Acetaminophen) - 2 Tablespoons (30 cc) every 4 hours as needed forfever or discomfort. Do not exceed 8 tablespoons in 24 hours.

Sudafed PE(Phenylephrine HCl) - 10 mg. 1 tablets every 4 hours as needed for nasalcongestion. Do not exceed 6 tablets in 24 hours.

Robitussin DM (Dextromethorphan and Guaifenesin) - 2 teaspoons (10 cc) every 4hours as needed for cough. Do not exceed 6 doses in 24 hours.

Chloraseptic Lozenges - One lozenge as needed for sore throat. Follow packagedirections.

Constipation:

Notify nurse if client has gone 3 days without having a BM. Notify nurse if client doesnot have a BM within 24 hours after giving laxative.

Milk of Magnesia - 2 tablespoons at bedtime as needed.

Diarrhea:

Notify Nurse. Avoid dairy products, high fiber foods, and caffeine. Give clear liquids,such as 7-Up, Gatorades, popsicles, Kool-Aid, or apple juice.

Immodium (Loperamide) - 2 mg. 2 tablets after 1st loose bowel movement, followed by 1tablet after each subsequent bowel movement. Do not exceed 4 tablets per day. Do notuse for more than 2 days.

Indigestion/Heartburn:

Notify nurse ofsymptoms unrelieved by medication. Notify nurse ofvomiting.

Maalox (Alumina and Magnesium) - 1 Tablespoon (15 cc) every 3-4 hours as needed.

TUMS Regular Strength (Calcium carbonate USP 500mg) - Chew 2 tablets every 3-4 hours as needed. Do not exceed 15 tablets in 24 hours.

Poisoning:

If client is unconscious, call 911.If client is conscious, call Poison Control immediately. 1-800-222-1222. Follow theirinstructions. Notify nurse.

Ipecac - administer only as directed by Poison Control.

Minor Wounds:

Notify nurse if area appears infected, if there is a question about the need for stitches,or if burned area is blistered.

Bacitracin Ointment -Apply a small amount to would 1-3 times daily as needed. Do notuse on deep wounds, puncture wounds, or burns unless directed by physician.

Mild Sunburn/Insect Bites/Minor Skin Irritation (i.e. Poison Ivy/Oak):

Notify nurse before applying to a rash. Do not apply to blistered, raw, or oozing skin.Discontinue use and consult physician if burning sensation or rash develops or ifcondition persists for more than 7 days.

Calamine Lotion -Apply liberally 3-4 times daily as needed. Before each application,clean area with soap and water and dry thoroughly; shake bottle well.

Rashes/Skin Inflammation:

Notify nursebefore use. Consult physician if condition persists for more than 7 days.

1 % Hydrocortisone Cream - Apply 3-4 times daily as needed. Do not apply to an arealarger than 10"X10" unless directed by physician. Avoid contact with eye area andmouth.

Athlete's Foot:

Notify nurseprior to use. Consult physician if condition persists for more than 2 weeks.Ensure that client's feet are washed and dried well daily. Encourage use of clean, white,cotton socks.

Micatin (Miconazole) - Apply cream sparingly to affected areas, including between toes, twice daily. Massage in well.

Dandruff:

Notify nurse ifthere are severe or patchy areas on scalp.

Selsun Blue (Selenium Sulfide) Shampoo - Use 1 -2 times per week as needed fordandruff. Shake well before use. Apply, lather, rinse, repeat. Rinse well. Avoid gettinginto eyes.

Dry Skin:

Notify Nurse ifareas do not respond to treatment within 5 days or if a rash develops.May use non-medicated hygiene/grooming products as needed or as directed by nurse.

Chapped Lips/Cold Sores:

Notify Nurse ifareas do not respond to treatment within 5 days.

Carmex - apply to lips 2-4 times daily as needed for chapping, fever blisters, or coldsores.

OR

Blistex -- apply to lips 2-4 times daily as needed for chapping, fever blisters, or coldsores.

May use non-medicated hygiene/grooming products as needed or as directed by nurse.

Prevention:

Sunburn - Use sunblock with SPF of 15 or greater. Follow direction on bottle.

Insect Bites - Deep Woods Off! (insect repellent with DEET) Follow package directions.

Other:

Physician’s Signature: ______Date: ______

Pharmacy: Bloomington Drug Phone: 952-884-7528 Fax:952-884-6366