Medical Form

Page 1

PHYSICAL EXAMINATION

Must be completed fully by a Licensed Physician for persons under 18 and/or persons of any age requiring medication assistance

Patient Name______Exam date:______

Address:______

City:______State:______Zip:______

Patient Phone # ( )______

Date of Birth ______/______/______Age:______

Height____ Weight_____ Blood Pressure_____

Vision (Please Check One)  Sighted  Totally Blind  Low Vision

Eye condition (Please Check All that Apply)  Cataracts  Glaucoma  Genetic/ Congenital  ROP  Macular Degeneration   Diabetic Retinopathy

 Other(s): ______

Has this patient had a serious illness or surgery within the past year?  Yes  No

Describe: ______

Is surgery planned prior to attending VISIONS?  Yes  No

Type of surgery: ______

Please Check for Yes and X for No All that Apply)  walking  floor/chair exercises  fitness center/use of equipment  yoga  swimming  dance  bowling  tandem bikes  lifting (i.e. horseshoes)  sports  other______

 May participate without restrictions

 Not recommended to participate, for the following reasons:

______

______

HEALTH HISTORY

Has the patient experienced any of the following health problems?

Amputation(s) Describe: ______ Yes  No

Asthma ......  Yes  No

Autism ......  Yes  No

Cerebral Palsy ......  Yes  No

Cognitive Impairment Describe: ______ Yes  No

Diabetes * ......  Yes  No

Emphysema/COPD ......  Yes  No

Fainting/Dizziness ......  Yes  No

Gait/Balance Difficulties ......  Yes  No

Hearing Impairment ......  Yes  No

Hypertension/High blood pressure ......  Yes  No

Incontinence -If yes note frequency: ______ Yes  No

Patient Name______Page 2

Must be completed fully by a licensed physician) (continued)

Intellectual/Developmental Disability ......  Yes  No

 Mild  Moderate  Severe  Profound

Multiple Sclerosis ......  Yes  No

Neurological disorder ......  Yes  No

Psychiatric…………………......  Yes  No

Seizure Disorder ......  Yes  No

 Petit Mal  Grand Mal (frequency) Last Seizure: ______

History of Self-Destructive Behavior......  Yes  No

Other, Describe: ______ Yes  No

Ambulation/Support Devices?______ Yes  No

Wheelchair User?______ Yes  No

Prosthetic Devices? ______ Yes  No

(Describe) ______  Yes  No

* If Diabetic patient uses insulin, please provide specific orders: ______

______

ALLERGIES

(Please List any Allergies):

______

______

Please provide specific orders and List medications required for allergic reaction ______

______

______

[ Be aware that participants attending VISIONS may be required to walk or travel more than the distance of two city blocks to dining and activity areas a minimum of three times a day, outdoors, on uneven terrain.
Patient Name______Page 3

[ NOTE: VISIONS will NOT provide glucose monitoring devices to participants. If the participant is diabetic, they MUST provide their own glucose testing kit for the duration of their stay at VISIONS from 1 to 7 days.

MEDICATIONS

(Please indicate ALL medications currently being taken along with dosage and frequency)

NAME DOSAGE PRESCRIBED TIME

1.
2.
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HEALTH INSURANCE

Medicare # ______Medicaid # ______

Sequence # __ __

Private Insurance Name ______

Private Insurance # ______

Medical Doctor or Clinic Name ______

Phone # (______)______

Street Address/ City / State / Zip

______

Eye Doctor or Clinic Name ______

Phone # (______)______

Street Address/ City / State / Zip

______

Patient Name______Page 4

ANNUAL PHYSICIAN ORDER
FOR OVER-THE-COUNTER (OTC) MEDICATION ADMINISTRATION
TO ALL PARTICIPANTS AT VISIONS
Medications/Treatments / Administration Directions /

Yes

/ No
Acetaminophen (Tylenol) 650 mg
____Adult ____Children / ADULT: 2 tabs, po, q4h, up to a maximum of 12 tabs in 24 hrs. PRN for headache, toothache, backache, muscular aches, minor arthritis pain, elevated temps (above 100), menstrual pain.
CHILDREN: Under 6 yrs – consult doctor,
6 – 11 yrs of age 2 teaspoons, po,q6h
Non-Narcotic Antitussive (Robitussin) / Two tsp., po, q4h. PRN for cough. Not to exceed 12 tsp. In 24hrs.
Cough drops (sugarless) for Diabetic / 1 drop, po, q1h for cough.
Cough drops / 1 drop, po, q1h for cough.
Alum/Magnesium Hydroxide Liquid with simethicone (eg. Mylanta) / 30cc, po. PRN for acid indigestion, heartburn, sour stomach, or flatulence.
Pepto Bismol Liquid / 30cc, po. PRN for nausea, heartburn, upset stomach, and diarrhea.
Imodium Liquid / 30cc, po. PRN for first episode of diarrhea and if continues then 10cc.
Milk of Magnesia / 30cc po. PRN for constipation followed by 8 oz of water.
Bacitracin / 500 units. PRN for minor cuts, wounds, burns, and abrasions.
Calamine / Apply freely. PRN for itching due to insect bites or other minor skin irritations.
Benadryl
____Adult ____Children / ADULT: Age 12 yrs to Adult, 2 - 4 tsp, po
CHILDREN: Age 6-12 yrs, 1 - 2 tsp, po

Doctor’s Name (Print)______

Phone ( )______Ext.______

Address______Zip______

Doctor’s Signature______Date______

* Please Note: Doctor’s License stamp or medical facility stamp MUST be included with signature. Medical form will not be accepted without it. Rev. 11/27/13 RC