Esph Patient History Form Page 3

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MRN:
SURNAME:
OTHER NAMES:
PATIENT HISTORY FORM
DOB:
SEX:
AMO:
(Affix Addressograph Label Here - Hospital use only)
To be completed by Patient or Carer.
Please PRINT clearly. Your responses are valuable in planning your admission and caring for you during your stay.
DISCHARGE PLANNING
This information is necessary in order to help you plan a safe return to home after discharge. ALL patients to complete
Are you over 80 years of age?
Do you live alone?
I have no one to look after me after discharge.
or, name of person
Relationship
Are you solely responsible for the care of another person at home?
Do you currently receive community support services?
Do you require assistance with any aspect of day to day living?
Details
Where do you plan to go after discharge?
How will you get there?
Name of person completing form:
Relationship:
Date:..../......../......
NURSES USE ONLY
RISK SCREENING
NO
YES
COMMENTS
NURSING NOTES
Completed and attached
Fall risk screen required (day surgery patients who have been
Refer to Policy
identified as a risk and all overnight patients)
Yes
No
Completed and attached
Pressure Injury risk screen required (day surgery patients who
have been identified as a risk and all overnight patients)
Yes
No
Patient history form reviewed by Pre-admission / Admitting nurse
Yes
No
Name of admitting nurse:
Date:
Signature:
Designation:
Time:
Patient history form reviewed by DSU / Ward Staff
Yes
No
Name of DSU / Ward nurse:
Date:
Signature:
Designation:
Time:
CLINICAL / PRE-ADMISSION NOTES
17

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