print a new patient packet - Banner Alzheimer's Institute

More documents

Recommendations

Info

MEDICATION HISTORY ALLERGIES PLEASE LIST ALLERGIES TO MEDICATIONS: PLEASE LIST ALLERGIES TO FOODS: PLEASE LIST OTHER ALLERGIES: PLEASE LIST ALL MEDICATIONS TAKEN WITHIN THE LAST MONTH: PRESCRIPTION MEDICATIONS DRUG NAME DOSE TIMES PER DAY DATE STARTED DATE STOPPED MEDICAL CONDITION BEING TREATED OVER THE COUNTER MEDICATIONS DRUG NAME DOSE TIMES PER DAY DATE STARTED DATE STOPPED MEDICAL CONDITION BEING TREATED VITAMINS DRUG NAME DOSE TIMES PER DAY DATE STARTED DATE STOPPED MEDICAL CONDITION BEING TREATED Page 3 of 6
SOCIAL HISTORY YEARS OF EDUCATION PREVIOUS OR CURRENT OCCUPATION YEARS IN OCCUPATION CURRENT LIVING SITUATION: ALONE IN HOME/ APT WITH SPOUSE/ FAMILY/ FRIEND ASSISTED LIVING NURSING HOME OTHER SUBSTANCE USE HISTORY ALCOHOL USE YES NO HAS THE PATIENT EVER USED ALCOHOL EXCESSIVELY CURRENT USE: HOW MANY DRINKS PER WEEK PAST USE: HOW MANY DRINKS PER WEEK TOBACCO USE YES NO DOES THE PATIENT CURRENTLY SMOKE IF NO, DATE OF CESSATION: IF PATIENT EVER SMOKED: # OF PACKS PER DAY: # OF YEARS SMOKED: SUBSTANCE USE YES NO HAS THE PATIENT EVER MISUSED LEGAL OR ILLEGAL SUBSTANCES IF YES: TYPE: DURATION: FAMILY HISTORY DOES THE PATIENT HAVE A BLOOD RELATIVE WITH SYMPTOMS OF OR DIAGNOSIS OF: YES NO DEMENTIA/SENILITY/ALZHEIMER’S IF YES, RELATIONSHIP: YES NO PARKINSON’S IF YES, RELATIONSHIP: YES NO STROKES IF YES, RELATIONSHIP: YES NO PSYCHIATRIC/MENTAL ILLNESS IF YES, RELATIONSHIP: YES NO MENTAL RETARDATION IF YES, RELATIONSHIP: YES NO DOES THE PATIENT HAVE LIVING SIBLINGS WITHOUT DEMENTIA PLEASE LIST DISEASES/ILLNESSES IN THE IMMEDIATE FAMILY: Page 4 of 6
Page 1 and 2: 901 E. Willetta Street Phoenix, Ari
Page 3: CURRENT PROBLEM WHAT IS THE MAIN RE
Page 7 and 8: HEALTH INSURANCE PLEASE COMPLETE TH

print a new patient packet - Banner Alzheimer's Institute

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?