Patient Summary Form
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PATIENT SUMMARY FORM
Name: ___________________________________________________________
Date of Birth: ____ /____ /____
Age: ________
Home Phone #: _________________________
Cell Phone #: _______________
E-mail: ________________________________
Primary Language: __________________________
EMERGENCY CONTACT:
Name: __________________________________________ Phone #: ______________________
MEDICAL HISTORY:
Are you currently receiving any Home Care Services?
I
Yes
I
No
Are you currently receiving any other Therapies?
I
Physical
I
Occupational
I
Speech
I
None
Current quality of life/health status:
I
Excellent
I
Very Good
I
Good
I
Fair
I
Poor
I
Please check Yes or No as appropriate for the following conditions.
Attached PMH provided by patient.
I
I
I
I
I
I
Asthma / Wheezing /
Yes
No
Cataracts
Yes
No
Circulatory Problems
Yes
No
Shortness of Breath
Glaucoma
I
Yes
I
No
Blood Clot
I
Yes
I
No
Frequent Cough
I
Yes
I
No
Low Blood Pressure
I
Yes
I
No
Leg Wounds
I
Yes
I
No
Pneumonia
I
Yes
I
No
High Blood Pressure
I
Yes
I
No
Diabetes
I
Yes
I
No
Sinus Infections
I
Yes
I
No
Congestive Heart Failure
I
Yes
I
No
Kidney Disease / Renal
I
Yes
I
No
Weight Changes: gain / loss
I
Yes
I
No
(CHF)
Failure
Frequent Laryngitis
I
Yes
I
No
Heart Disease
I
Yes
I
No
Thyroid Disorder
I
Yes
I
No
I
I
I
I
I
I
Frequent Sore Throat
Yes
No
Pacemaker
Yes
No
Incontinence
Yes
No
Difficulty Swallowing
I
Yes
I
No
Arthritis
I
Yes
I
No
Bowel Irregularity
I
Yes
I
No
GERD/Reflux
I
Yes
I
No
Osteoporosis / Osteopenia
I
Yes
I
No
Urinary Frequency / Urgency
I
Yes
I
No
Poor Appetite
I
Yes
I
No
Chronic Back Pain
I
Yes
I
No
Bladder Infections
I
Yes
I
No
Frequent Nausea / Vomiting
I
Yes
I
No
Peripheral Neuropathy
I
Yes
I
No
Tuberculosis
I
Yes
I
No
Hearing Loss
I
Yes
I
No
Aneurysm
I
Yes
I
No
Immune Deficiency
I
Yes
I
No
I
I
I
I
I
I
Vertigo / Dizziness
Yes
No
Seizure
Yes
No
Anxiety
Yes
No
I
I
I
I
I
I
TMJ
Yes
No
Stroke / TIA
Yes
No
Depression
Yes
No
Panic Attacks
I
Yes
I
No
Diagnosis of Cancer
I
Yes
I
No
If yes, state type of cancer __________________________________________________
Date diagnosed: _____________________
Radiation
I
Yes
I
No
Chemotherapy
I
Yes
I
No
SURGICAL HISTORY: List any surgical history. Please include dates or time frame:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
ADDITIONAL MEDICAL HISTORY:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
MEDICATIONS:
I
NONE
I
Attached medication list provided by patient.
Please CLEARLY LIST any medications you are taking, including herbals and over the counter medications:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
ALLERGIES:
Latex:
I
Yes
I
No
Please list others: ___________________________________________________________
Please Turn Over
GSPPPTF204
DO NOT USE UNAPPROVED ABBREVIATIONS
GSPPPTF204
GSPPPTF-204
AEL 5/2012
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