New Patient Family Report Form - Delnor Hospital

New Patient Family Report Intake FormInstructions: This form will take 15-20 minutes to complete. Please take the necessary time to gatherinformation and carefully answer all questions. If you are filling this out for another individual, pleaseconsult with family members or friends who may have additional information. If you do not know the answerto a question, please write "DK."PATIENT INFORMATIONName:Address:DOB:Phone:Age:Is English the patient's primary language?YesNoIf no, please list patient's primary language:Does the patient have a designated power of attorney for health care, or a court-appointed legal guardianwho is regularly involved in making the patient's health care decisions?YesNoIf yes, please specify: Power of attorney Court-appointed guardianIf yes, please state name and phone number for the guardian or power of attorney, and havehim/her sign the signature line below:Name:Phone:Signature:INSURANCE INFORMATIONInsurance Company:Name of Policy Holder:Date of Birth:Policy Number:Group Number:Phone # for Claims:If applicable, provide information for additional policy below:Insurance Company:Name of Policy Holder:Date of Birth:Policy Number:Group Number:Phone # for Claims:OBSERVER INFORMATION (To be completed by individual filling out this form)Name:Address:How often are you with the patient?Live with the patientWith patient dailyPhone:Relationship to Patient:See patient several times each weekSee patient a couple of times permonthOther:Please list below the individual(s) who will be accompanying the patient to the clinic:1

PURPOSE OF EVALUATIONWhy are you seeking evaluation for the patient at this time?Was the patient referred to this clinic by a health care professional, familymember, or is he/she self-referred?What were the first problems noticed?When were the first problems noticed?How did the problems appear?Started suddenlyAppeared gradually over timeHow would you describe the problem(s)?Steadily worseningFairly stable over timeSteadily improvingTendency to come and go (good days and bad days)Are there any circumstances or activities that result in improvements in the patient's symptoms?YesNoIf yes, please describe:What are the most important things you would like to see accomplished with this evaluation?MEDICAL INFORMATIONPrimary Care Physician:Address:If yes, approximately when was the patient seen?Phone:Has the patient seen his / her primary care physician about the current issue?Has the patient been seen by any other doctor or specialist about the current issue?(e.g., neurologist, psychiatrist, psychologist)If yes, please listdoctors and contactinfo:YesYesNoNoHas the patient ever seen a neurologist for any reason? Yes NoIf yes, when and why was he/she seen?Have any tests concerning this issue been performed in the past two years? (e.g.,MRI, CT scan, lab work, blood work, neuropsychological testing)YesNoIf yes, please list:Test PerformedOrdering Physician2

MEDICAL HISTORYPlease mark any of the following conditions that the patient has had, and indicate the year when eachstarted. If not certain, please write down an approximate year or age when the problem began.Neurological IllnessYearCardiac IllnessYearHead InjuryHeart AttackStrokeHigh Blood PressureSeizures / ConvulsionsHigh CholesterolMultiple SclerosisChest PainParkinson's DiseaseBypass SurgeryFainting SpellsStent PlacementDizzinessCongestive Heart FailureShortness of breathAtrial FibrillationHeadachesPalpitationsMigraine HeadachesOtherneurologicalillness (pleaselist):General Medical IllnessYearYearAsthmaGastrointestinal ProblemsCancerDiabetesThyroid DiseaseSignificant Weight LossCOPD / EmphysemaSignificant Weight GainAllergies / HayfeverDifficulty SwallowingFrequent HospitalizationsExposure to ToxinsGlaucomaRinging in the EarsCold or Heat IntoleranceUnexplained FatigueIncontinenceOtherDoes the patient suffer from chronic or severe pain?YesNoIf yes, please describe the location and severity (scale of 1-10) of the pain:Please list any major childhood illnesses:Please list any prior surgical procedures:Is there a family history of dementia or Alzheimer's disease?If yes, please describe:YesNoIs there a family history of memory loss?If yes, please describe:YesNo3

Speech and Language (Check all that apply)Difficulty recalling the names of common objectsEffortful speech (i.e., appears like he/she has to "force" words to come out)Using the wrong names for things (e.g., calling the TV a radio)Difficulty finding the right word (e.g., word is on the tip-of-the-tongue, but they can'tcome up with it)Slurred speech, stuttering speech, or speech that does not flow smoothlyUsing made-up words (e.g., calling the remote control a "point-at-er")Difficulty understanding what others are sayingSignificant change in speech volume (e.g., speech has become much softer)Difficulty readingChange in handwriting (e.g., becoming smaller; becoming more difficult to read;taking longer to write)Other language problems (please describe):Visual Functioning (Check all that apply)Reports double visionReports blurry visionBrief periods of blindnessNeeds to squint or move closer to objects in order to see themSensitivity to bright lightsDifficulty finding objects that are in plain sightWalking into objects (e.g., the edge of a doorway, the corner of a table)If yes, are objects on the:rightleftboth sidesdon't knowDifficulty recognizing familiar peopleDifficulty recognizing familiar places (e.g., not knowing where they are, even in theirown home)Gets lost easilyOther visual problems (please describe):Memory (Check all that apply)Rapid forgetting (e.g., repeating the same question within five or ten minutes)Frequently loses important things (e.g., keys, credit cards)Forgets the names of familiar peopleForgets events from the pastDifficulty remembering recent events (e.g., forgets a conversation from a few days before)Has difficulty learning new things (e.g., how to operate a new microwave)Other memory problems (please describe):6

Motor & Sensory Functioning (Check all that apply)Problems with balanceHas a slowed and/or unsteady gaitUses an assistive device (e.g., cane, walker, wheelchair)Difficulty getting out of a chairTendency to fallIf yes, does patient fall:backwardforwardto the sidedon't knowWeakness on one side of the bodyIf yes, please indicate:Shaking or tremorsrightleftReports loss of feeling or numbnessReports tingling or other unusual sensationsReports loss of sense of taste or smellHas tics or other unusual movementsDifficulty with fine motor control (e.g., difficulty accurately pushing the buttons onthe telephone)Difficulty with well-learned motor tasks (e.g., operating the telephone or the remote control)Needs assistance with daily activities because of mobility difficulty (e.g., dressing,bathing, eating)Can perform daily activities, but is significantly slowerOther motor problems (please describe):Home / Community Functioning (Check all that apply)Avoids bathingEats the same food every dayAvoids changing clothesHas difficulty getting dressed because of confusionFails to keep up appearance (e.g., dirty clothes, unkempt hair)Poor hygiene (e.g., doesn't brush teeth, doesn't clip nails, doesn't wash hands)Trouble with toiletingTendency to wanderNot keeping up the home (e.g., dishes not washed, garbage not taken out, spoiledfood in refrigerator)Difficulty cooking (e.g., burns food, leaves stove on, forgets simple recipes)Trouble with bill paying (e.g., missed payments, late charges)IncontinenceIf yes, please specify:bladderbowelbothDifficulty making correct change in a store or restaurantChanges or concerns with sexual behaviorOther functioning problems (please describe):7

Emotional Functioning, Personality, & Mental Health (Check all that apply)Appears sad much of the time (e.g., has frequent crying spells)Has episodes of euphoriaPreoccupied with deathMakes suicidal statements (e.g., "It would be better if I wasn't here")Appears anxious much of the timeDifficulty falling asleepTendency to pace or otherwise appear agitatedSeems to have obsessions with certain topics (e.g., finances)Paranoia - has irrational fears (e.g., spouse having affair, children stealing money,house being broken in to)Inappropriate laughing (e.g., loud laughing that is out of context; constant giggling)Shows loss of inhibitions (e.g., makes inappropriate sexual comments)Is much more emotional than usualDoesn't seem to enjoy activities that were once pleasurableIncreasing inactivity and lack of participation in activitiesPatient's personality has changedSudden or rapid swings in moodAngry or irritable more than usualAgitated (e.g., pacing the floor)Change in sexual behaviorAggressive behavior (e.g., hitting, yelling, making threats)Has been observed experiencing hallucinations (i.e., responding to sensory stimulithat are not real)If yes, pleasespecify:visualauditorytactile (e.g., feeling things on skin)Other emotional problems (please describe):Driving (Check all that apply)Is the patient currently driving?YesNoIf no, when did he/she stop?Why?If yes, please answer the following:Drifts over the line when drivingDifficulty finding familiar destinationsDrives too close to other vehiclesDrives too slowly (e.g., 20 mph in a 45 mph zone)Ignores the advice of family or health care providers to stop drivingGets lost and needs to call for directions, or gets lost and simply shows up severalhours laterOther driving problems (please describe):8

Other Symptoms (Check all that apply)Does not like changes in routineDifficulty distinguishing dreams from realityConfusion late in the dayAwakening at night (i.e., disruption of day/night pattern)Excessive sleeping (more often asleep than awake)Frequent nightmaresPlease use the space below to describe any additional symptoms that you believe need to be considered inthis evaluation:ACADEMIC HISTORYPERSONAL HISTORY INFORMATIONSome historical information will help us better understand the patient.How many years of education does the patient have (check one):Did not complete high schoolIf patient did not complete high school, please specify how manyyears of school were completed:If patient did not complete high school, did he/she earn a GED?Completed high schoolCompleted some college, did not earn a degreeIf patient did not earn a degree, please specify how many years ofcollege were completed:Completed vocational or trade training / apprenticeshipYesNoCompleted 2-year degreeField of study?Completed 4-year degreeField of study?Completed Masters degreeField of study?Completed Doctoral degreeField of study?What type of student is/was the patient?below averageaverageabove averageWas the patient considered to have a learning disability or to be a "slow learner?"YesNoDid the patient have behavioral difficulties in school?YesNoAre there concerns about school functioning or returning to school? Yes NoVOCATIONAL HISTORYWhat was/is the patient's primary career? (please list "homemaker" if appropriate):Do you have concerns about working or returning to work? If yes, describe:YesNoHas the patient retired?YesNoIf yes, when:Please list brief work history:Position HeldYears Held (approximate)9

SOCIAL HISTORYWhere was the patient born?Who was the patient raised by?How many siblings does the patient have?Did the patient have severe early-life stress (e.g., loss of parent, divorce, physical or sexual abuse,exposure to war)?YesNoIf yes, please explain:Has the patient had any recent severe stress (e.g., death in the family, severe financial stress)?YesNoIf yes, please explain:Marital Status:MarriedSingleDivorcedWidowedOtherIf currently married, how many years has the patient been married?Does the patient have any children?YesNoIf yes, please list children and the city and state where they live:Who is/are the patient's primary source(s) or emotional support?Does the patient maintain regular social contacts?If yes, with whom:Does the patient participate in recreational activities?If yes, describe:YesYesNoNoWhat is the patient's current living arrangement? (check one):Lives at home independentlySenior communityWho currently lives with the patient?Lives at home with assistanceAssisted livingLives with familyResidential CareIs the patient home alone during the day?Who currently takes care of the patient's finances?MENTAL HEALTH HISTORYHas the patient ever received treatment by a psychiatrist, psychologist, or counselor?If yes, when was patient treated?What was patient treated for (diagnosis)?YesNoHas the patient ever been psychiatrically hospitalized?YesNoDon't KnowDoes the patient have a history of suicidal thoughts or behavior?YesNoDon't KnowHas the patient ever made a suicide attempt? Yes NoDon't KnowDoes the patient have a history of homicidal thoughts or behavior?YesNoDon't KnowDoes the patient have a history of alcohol abuse?YesNoDon't KnowHas the patient ever experienced alcoholic blackouts or "DTs"?YesNoDon't KnowHas the patient ever used recreational drugs?YesNoDon't KnowIf yes, what drugs have been used?Has the patient ever abused prescription drugs?YesNoDon't KnowIf yes, what drugs were abused?Has the patient ever been treated for alcohol or substance abuse?YesNoDon't KnowHas the patient had alcohol or substance-related legal problems?10YesNoDon't Know

CAREGIVER FUNCTIONINGThe questions in this section refer to the functioning of the primary caregiver, not the patient.Please have this section filled out by the primary caregiver, or the person most closely fitting thatrole.If the person filling out this section is different than the person filling out the rest of this form, please writetheir name below:As the primary caregiver:Do you feel you have enough support?If no, what do you most need?Would you like information regarding a temporary place where the patient can go sothat you can get necessary rest and relief?Would you like information regarding residential facilities that care for people withmemory or behavior concerns?Would you like information about assistive devices (e.g., wander bracelets, homeadaptations)?Would you like referrals for attorneys to assist with legal matters (e.g., power ofattorney, wills, advance directives)?Would you be interested in a trial of counseling to help you meet your own needs asa caregiver?Is there disagreement or conflict among family members regarding the patient'sneeds?If yes, would you like a family meeting to gather adult children and otherresponsible persons, to review the patient's situation?YesYesYesYesYesYesYesYesNoNoNoNoNoNoNoNoPlease complete this form and bring it to the appointment or return it to us in one of thefollowing ways:a.Fax to Delnor Psychological Services at 630-208-3007b.Mail to the following address:Psychological ServicesDelnor Hospital300 Randall RoadGeneva, IL 60134If you have any questions about completing this form, please call Delnor PsychologicalServices at (630)524-5845.11