Physician'S Assessment And Initial Order Form - Helping Hands Adult Day Services (Page 2 of 2) in pdf

Physician'S Assessment And Initial Order Form - Helping Hands Adult Day Services Page 2

Page 2 – PHYSICIAN’S ASSESSMENT AND INITIAL ORDER FORM (Cont’d)

Client’s Name: _____________________________________________

KNOWN ALLERGIES: ___________________________________________________________________________________________________

MEDICATION ORDERS:

Medication

Dosage & Frequency

Restrictions

Date Started

Tylenol 2 tabs p o q4h PRN for headache, minor pain or fever above 101 degrees

Other treatments/assessments, i.e., BP monnitoring, dressings, glucose monitoring via finger stick, etc.

Treatment/test

Frequency

Administered by

May this patient self medicate?

Yes _______ No _______

The Center offers a regular exercise program. Specific structured therapies (OT/PT) are available as a supplement

to our program. If you wish your patient to receive occupational and/or physical therapies, please attach a

physician’s order with your detailed intructions.

Orders attached: Yes _______ No _______

Date: ____________________________________ Signature: ___________________________________________________________________ M.D.

Doctor, please provide your mailing address and phone number:

Doctor:

Phone:

Fax:

Address:

City:

State:

Zip:

Specialty:

Date last seen:

Next Appointment:

Current Specialty Providers:

Doctor:

Phone:

Fax:

Address:

City:

State:

Zip:

Specialty:

Date last seen:

Next Appointment:

Phy Fm 101 Eff 07/01/05

Rev. 02/16

Physician'S Assessment And Initial Order Form - Helping Hands Adult Day Services Page 2

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