Home Care Questionnaire Page 2
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1
2TO BE COMPLETED BY THE TREATING PHYSICIAN
(PLEASE PRINT CLEARLY)
7. PATIENT CLINICAL INfORMATION
Please provide an answer to all the following questions
Was the patient hospitalized?
No
Yes
Y
M
D
Y
M
D
If yes, specify date of admission
and date of discharge
Y
M
D
Did the patient undergo day surgery?
No
Yes If yes, specify the date of surgery
Y
M
D
Did the patient receive care/treatment in the emergency room?
No
Yes If yes, date of consultation at the emergency room
Length of stay under observation at the emergency room (number of hours) ___________________________________________________________________________
The specific medical reasons that required hospitalization, surgery or one-day consultation at the emergency room _______________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Please specify the nature of the surgery ___________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
What other health problem(s) does your patient have? ______________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Description of care required _____________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Name of provider of home care service ___________________________________________________________________________________________________________
Is he or she an immediate family member (spouse, mother, father, child, brother or sister of the insured)?
No
Yes
Address ___________________________________________________________________________________________ Phone number
Y
M
D
Length of time where home care is required
hours /
days until
Description of services
Hygiene
Mobilization
Weekly housekeeping
Food
Other __________________________________________________________________________________________________
___________________________________________________________________________________________________________
Is your patient in the terminal phase of an illness?
No
Yes
7. PATIENT CLINICAL INfORMATION
I hereby confirm that the above information is true and complete to the best of my knowledge.
Physician’s name _______________________________________________________________________________________ Telephone
Address _____________________________________________________________________________________________________ Fax
General practitioner
Specialist
Other
Specify ____________________________________________________________________________________
Y
M
D
Signature
Date signed
__________________________________________________________________________________________________________________________________
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Parent category: Medical