Patient Demographics Patient Demographics Step 1 of 5 20% Select Patient-- Select Patient --Patient Full NamePatient Name First Last Patient Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of birth MM slash DD slash YYYY AgeMarital StatusMarriedDivorcedSeparatedNever marriedSingleGenderFemaleMaleTransgenderOtherPrimary LanguageAdmission Date MM slash DD slash YYYY Medical Information Primary Care PhysicianPhonePhysician Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary DiagnosisOther DiagnosisDrug allergies and sensitivitiesDiet/Nutrition Regular Low Salt Puree/Chopped Diabetic/No concentrated Sweets Other Enter other if checked from abovePast Medical HistoryCondition/Ailment/DiseaseDatePast Surgical HistoryDate of SurgeryCondition/Ailment/DiseaseDatePast Surgical HistoryDate of SurgeryCondition/Ailment/DiseaseDatePast Surgical HistoryDate of SurgeryCondition/Ailment/DiseaseDatePast Surgical HistoryDate of Surgery Mental Status Angry Depressed Uncooperative Hostile Panic Flat Affect Anxious Phobia Agitated Paranoid Tics Spasms Obsessive/Compulsive Mood Swings Depressive feeling reported or observed None of the above Financial InformationFinancial Information Insurance Private Pay Medicaid # Emergency ContactName First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneRelationship General HealthTemperatureRespirationBlood PressureCurrent WeightTarget WeightFluidIdentify any changes over the past month:NoYesDiagnosisDescribe Change: TreatmentRespiratoryOtherWhen is the person noticeably short of breath?Respiratory treatments utilized at home:Genitourinary statusContent FrequencyOtherGastrointestinal StatusBowl FrequencyOtherBowel Incontinence FrequencyBowel Incontinence FrequencyPain/discomfortPain Frequency:Pain Site(s):Pain FrequencyPerson is experiencing pain that is not easily relieved, occurs at least daily, and affects the ability to sleep, appetite, physical or emotional energy, concentration, personal relationships, emotions, or ability or desire to perform physical activity. Cause of pain if known:Treatment:CardiovascularBlood Pressure BP and pulse within normal limits RhythmRUELUERLELLEEdemaOtherNeurological Cognitive FunctioningSpeechPupilsMovementsExtremitiesRight UpperLeft UpperRight LowerLeft LowerSensoryVision with corrective lenses if applicableHearing with corrective device if applicablePsychosocialIs this person receiving psychological counseling ? No Yes Behaviors reported or observedMusculoskeletalOtherMental HealthSkinPressure Ulcer Stages Redness of intact skin warmth, edema, hardness, or discolored skin may be indicators Stage 1 Number of Pressure UlcersPartial thickness skin loss of epidermis and/or dermis/ The ulcer is superficial and appears as an abrasion, blister, or shallow crater. Stage 2 Number of Pressure UlcersFull thickness skin loss: damage or necrosis of subcutaneous tissue; deep crater Stage 3: Number of Pressure UlcersStage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures. Stage 4: Number of Pressure UlcersLocation of UlcersSurgical or other types of wounds (describe location, size and nature of wound) Activity LevelsMobility and TransfersUses to aid in ambulatingBathingPersonal Hygiene: hair, skin, nails, oral careToilet: bladder, bowel routine, ability to access toiletDressingEating/DrinkingHealth maintenance NeedsPlease explain if other:General Physical ConditionPlease explain if other:Medication ManagementMedicationDoseFrequencyPhysicianPurposeMedicationDoseFrequencyPhysicianPurposeMedicationDoseFrequencyPhysicianPurposeMedicationDoseFequencyPhysicianPurpose Able to independently take the correct medications at the correct time Able to take medications at the correct time if: - Individual doses are prepared in advance by another person - Given daily reminders Unable to take medication unless administered by someone else No medications prescribed Other (please specify) Other CardiovascularBP and pulse within normal limits Yes No RythmRUELUELLERLEEDEMAOtherNeurologicalCognitive FunctioningSpeechPupilsMovementsExtremitiesRight UpperLeft UpperLower UpperRight UpperSensory Vision with corrective lenses if applicableHearing with corrective device if applicablePsychosocial Is this person receiving psychological counseling?NoYesBehaviors reported or observedMusculoskeletalOtherMental HealthSkinPressure Ulcer StagesStage 1: Redness of intact skin warmth, edema, hardness, or discolored skin may be indicatorsNumber of Pressure Ulcers Stage 2: Partial thickness skin loss of epidermis and/or dermis/ The ulcer is superficial and appears as an abrasion, blister, or shallow crater.Number of Pressure UlcersStage 3: Full thickness skin loss: damage or necrosis of subcutaneous tissue; deep craterNumber of Pressure UlcersStage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structuresNumber of Pressure UlcersLocation of UlcersSurgical or other types of wounds (location, size and nature of wound) Activity LevelsMobility and TransfersUses _______ to aid in ambulating:Uses ______ to aid in ambulating:BathingPersonal Hygiene: hair, skin, nails, oral careToilet: bladder, bowel routine, ability to access toiletDressingEating/DrinkingHealth maintenance NeedsExplain if otherGeneral Physical ConditionExplain if otherMedication Management:Medication 1DoseFrequencyPhysicianPurposesMedication 2DoseFrequencyPhysicianPurposesMedication 3DoseFrequencyPhysicianPurposes Able to independently take the correct medications at the correct time Able to take medications at the correct time if Individual doses are prepared in advance by another person Able to take medications at the correct time Given daily reminders Unable to take medication unless administered by someone else No medications prescribed Other (Please specify) NotesNurse Monitor Visit Initial Monthly 45 - day 3 - Month Patient Name First Last Caregiver Name First Last Patient Representative SignatureDate MM slash DD slash YYYY Name of Registered Nurse First Last Date MM slash DD slash YYYY Registered Signature