Medical Form For Adults - New Jersey Page 2
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2Form #5: page 2 of 2
D. MEDICATION:
Name: _________________
Dosage: ________
Frequency: _______
Indication:________
Name: _________________
Dosage: ________
Frequency: _______
Indication:________
Name: _________________
Dosage: ________
Frequency: _______
Indication:________
Name: _________________
Dosage: ________
Frequency: _______
Indication:________
Name: _________________
Dosage: ________
Frequency: _______
Indication:________
E. CLINICAL EXAMINATION:
1)
Height: _____ Weight: _____ Temp.: _____ Pulse: _____ B.P.: ______
2)
Sensory (Indicate any impairment and extent):
Eyes: Vision (Glasses, etc.):
Hearing: (Aids, etc.):
3)
ENT:
4)
Teeth & Gums:
5)
Neck:
6)
Breast (Follow American Cancer Society Guidelines for Mammography):
7)
Lymphatic System:
8)
Respiratory System:
9)
Cardiovascular System:
10) Gastrointestinal System (Stool for occult blood after age 50):
11) Genitourinary System:
12) Prostate:
13) Muscular System:
14) Skeletal System:
15) Neurological System:
ADDITIONAL INFORMATION/RECOMMENDATIONS:
(Please indicate if there are limitations or restrictions regarding physical activities)
PLEASE ISSUE PRESCRIPTIONS FOR MEDICATION, DIET, ADAPTIVE EQUIPMENT,
PROCEDURES AND THERAPIES.
(Please Print or Type CLEARLY)
Physician’s Name: ________________________________________
Date: __________________
Address: ______________________________________________
Phone #:
__________________
Physician’s Signature: ________________________________________________________________
PLEASE RETURN COMPLETED FORM TO:
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
THANK YOU FOR YOUR COOPERATION
DDD Day Program Manual 11/06
Forms: Form F5
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