Microsoft word - document

Health Information
1. GENERAL HEALTH: In general, how is this person's health? _______ Number of days of restricted activity because of illness 3. DENTIST VISITS: About how many times has the person been to the dentist in the past year? Number of times for exams, cleaning, and general preventive work Number of times for major work, surgery, or emergency situations 4. DOCTOR VISITS: About how many times has the person been seen by a doctor in the past year? Total times seen by doctors in past year (approximate)
About how many visits were for acute illness? About how many visits were for normal preventive care? About how many visits to an Emergency Room? About how many visits were to specialists? 5. What were the kinds of specialists most often seen? 5A ___________________________________________________________ 5B ___________________________________________________________ 5C ___________________________________________________________ 6. What was the reason for the most recent Emergency Room visit? 7. HOSPITAL ADMISSIONS: How many times in the past year has the person been admitted to a hospital for any reason? 8. What was the reason for the most recent hospital admission? 9. "MEDICAL HOME": Does this person have a clearly identified primary care physician who is responsible for primary care and 10. How is this person’s health care paid for? (Enter a “1” for all that apply.) _____ 10B Medicaid, in some variety of managed care, HMO, HSO, HIO, MCO, MSO, PSRO, etc.
11. PRESCRIBED DAILY MEDICATIONS: Please PRINT the name of each PRESCRIBED medication that the person is
receiving. Under PURPOSE, use these codes:
1 = Control of Psychiatric Symptoms (Neuroleptics, psychotropics, antipsychotics; commonly Mellaril, Haldol, etc.)
2 = Behavior Control, Calming (Major and minor tranquilizers) 3 = Sleep (Medications to induce or prolong sleep) 4 = Antidepressant (To reduce depression, withdrawal; to elevate mood) 6 = Digestive, Stomach, Bowel (For heartburn, ulcer, laxative, etc.) 7 = Chronic Health Condition (For heart, hypertension, diabetes, etc.) 8 = Nutritional Supplements (Vitamins, minerals, special supplements) NAMES OF PRESCRIBED MEDICATIONS
11R. How many errors in the administration of medications occurred in the past month? Do not include errors in documentation. _______ medication errors other than documentation (enter zero if none) 11S. Please describe the most recent medication error, if any. _____ 3 At or Near Weight Ideal for Height and Build 13. WEIGHT GAIN OR LOSS: Has this person gained or lost weight within the past year? 14. Who has evaluated the SIGNIFICANT weight gain or loss? (Enter “1” for all that apply.) _____ 14E Other (specify: __________________________________________) _____ 14F None needed -- no SIGNIFICANT weight gain or loss 15. Describe the process of finding medical care for this person: 16. Please describe the relationship between this person and the primary care physician. 1 Very negative (such as cold, uncaring, fearful, etc.) 5 Very positive (such as pleasant, warm, patient, gentle, caring) 17. RESPONDENT OPINION: Overall, how good is this person's health care? 18. INJURIES: How many injuries requiring medical attention has this person had in the past year? 19. ABUSE or NEGLECT: How many events of abuse, mistreatment, or neglect have been alleged about this person in the past year? 20. RESTRICTIVE PROCEDURES: Approximately how many times have restrictive procedures been used with this person in the **_______ # of times restrictive procedures used

Source: http://www.eoutcome.org/Uploads/COAUploads/PdfUpload/PLQHealthInfo.pdf