Form Rfpc - Regional Forensic - Psychiatric Center - Preadmission Contact Page 3
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4PREADMISSION CONTACT
NAME:________________________________________
PHYSICAL PROBLEMS (Including recent injury(ies); chronic pain; sensory limitation or others as noted):
__________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________
ANY CURRENT/ACUTE/CHRONIC INFECTIOUS DISEASE?
YES
NO If yes, explain________________________
__________________________________________________________________________
AMBULATION: UNAIDED
CANE
CRUTCHES
WALKER
WHEELCHAIR
PROSTHESIS
SPECIFY:__________________________________________________________________________________________
IMMUNIZATIONS (Include PPD)
DATE ADMINISTERED
1.
2.
3.
RECENT PSYCHOLOGICAL TESTS:
YES
NO
DATE OF REPORT: ____________
PRIOR PSYCHIATRIC HOSPITALIZATIONS: _____________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
DRUG, ALCOHOL AND NICOTINE HISTORY:_____________________________________________________________
DRUG AND ALCOHOL TREATMENT HISTORY: __________________________________________________________
___________________________________________________________________________________________________
ADVANCE DIRECTIVES: MEDICAL: YES
NO
PSYCHIATRIC: YES
NO
ORGAN DONOR:
YES
NO
INCOME:
YES
NO
SOURCE:____________________________ AMOUNT:____________________________
MEDICAL INSURANCE INFORMATION:_______________________________________________________________
MEDICAL ASSISTANCE #: _____________________MEDICARE#:__________________________
MEDICARE D PLAN: ______________________________________ ID #:_____________________________________
NEXT OF KIN/SIGNIFICANT OTHERS:
(1)NAME:__________________________________________________ RELATIONSHIP: _________________________
ADDRESS________________________________ CITY, STATE, ZIP CODE____________________________________
PHONE: (H)______________________(W)_____________________CELL PHONE_______________________________
(2)NAME:__________________________________________________ RELATIONSHIP: _________________________
ADDRESS:________________________________ CITY, STATE, ZIP CODE___________________________________
PHONE: (H)______________________(W)_____________________CELL PHONE_______________________________
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RFPC 2010-9
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