Va Form 10-10sh - State Home Program Application For Veteran Care Medical Certification
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3OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
STATE HOME PROGRAM APPLICATION FOR VETERAN CARE
MEDICAL CERTIFICATION
PART I - ADMINISTRATIVE
STATE HOME FACILITY
DATE ADMITTED
GENDER
M
F
RESIDENT'S NAME (Last, First, Middle ) (This is a mandatory field)
SOCIAL SECURITY NUMBER. (Mandatory field)
RESIDENT'S STREET ADDRESS
AGE
DATE OF BIRTH (mm/dd/yyyy)
CITY, STATE AND ZIP CODE
ADVANCED MEDICAL DIRECTIVE
NO
YES
PART II - HISTORY AND PHYSICAL (Use separate sheet if necessary)
HISTORY
HEIGHT
WEIGHT
TEMP
PULSE
BP
HEAD/EYES/EAR/NOSE AND THROAT
NECK
CARDIOPULMONARY
ABDOMEN
GENITOURINARY
RECTAL
EXTREMITIES
NEUROLOGICAL
ALLERGY/DRUG SENSITIVITY
DATE (mm/dd/yyyy)
RESULTS
DATE (mm/dd/yyyy)
RESULTS
CHEST
CBC
X-RAY
X-RAY/
SEROLOGY
LAB
DATE (mm/dd/yyyy)
ALBUMEN
SUGAR
ACETONE
URINALYSIS
CHECK ALL BOXES THAT APPLY OR CHECK NA
IS DEMENTIA THE
IS THERE A DIAGNOSIS OF MENTAL ILLNESS
HAS RESIDENT RECEIVED MENTAL
IS CLIENT A DANGER TO SELF OR OTHERS
PRIMARY DIAGNOSIS
SERVICES WITHIN THE PAST 2 YEARS
YES
NO
YES
NO
YES
NO
YES
NO
IS THERE ANY PRESSING EVIDENCE OF MENTAL ILLNESS SUCH AS:
SCHIZOPHRENIA
PARANOIA
OTHER PSYCHOTIC OR MENTAL DISORDERS LEADING TO CHRONIC DISABILITY
MOOD SWINGS
SOMATOFORM DISORDER
PANIC OR SEVERE ANXIETY DISORDER
PERSONALITY DISORDER
TUBE FEEDING
DECUBITUS ULCERS
OXYGEN
FOLEY CATHETER
PRN
MASK
OSTOMY
DRAINING WOUND
TEMPORARY
NASAL CANULAR
CONTINUOUS
TRACHOSTOMY
WOUND CULTURED
PERMANENT
REFERRING PHYSICIAN
PRIMARY DIAGNOSIS
SECONDARY DIAGNOSIS
TERTIARY DIAGNOSIS
TYPE OF CARE RECOMMENDED:
SKILLED NURSING HOME CARE
DOMICILIARY CARE
ADULT HEALTH CARE
HOSPITAL
MEDICATION AND TREATMENT ORDERS ON ADMISSION, CONTINUE ON SEPARATE SHEET IF NECESSARY
PRINTED OR TYPED NAME OF PRIMARY PHYSICIAN ASSIGNED
SIGNATURE OF PRIMARY PHYSICIAN ASSIGNED
VA FORM
10-10SH
PAGE 1
EXISTING STOCK OF VA FORM 10-10SH, DATED JUL 1998, WILL BE USED.
APR 2009
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