Brs-3947w - Afc Licensing - Health Care Appraisal
Download a blank fillable Brs-3947w - Afc Licensing - Health Care Appraisal in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Brs-3947w - Afc Licensing - Health Care Appraisal with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1AFC LICENSING - HEALTH CARE APPRAISAL
Michigan Department of Consumer and Industry Services
Licensee Name
Resident Name
Case Number
AFC Facility Name
Facility License Number
Worker Name/ Load #
Worker Phone Number
Release of General Medical Information:
By signing this form, I understand that I am authorizing the release of medical information concerning me to the licensee and licensee’s staff, the responsible
agency, and the Michigan Department of Consumer and Industry Services, Bureau of Regulatory Services for the purpose of providing appropriate care to me and determining compliance with licensing rules.
Signature of Resident/Legal Guardian
Title
Date
Release of HIV/AIDS/ARC Information:
By signing this form, I understand that I am authorizing the release of medical information concerning me , including information regarding Acquired
Immunodeficiency Syndrome (AIDS), Aids Related Complex (ARC), or Human Immunodeficiency Virus (HIV), if applicable to the licensee and licensee’s staff, the responsible agency, and the Michigan Department of Consumer
and Industry Services, Bureau of Regulatory Services, for the purpose of providing appropriate care to me and determining compliance with licensing rules.
Signature of Resident/Legal Guardian
Title
Date
1.Height
2.Weight
3.Ideal Weight Range
4.Blood Pressure
5.Age
6.Sex
MALE
FEMALE
7 Diagnoses
15. Physical Exams:
**
NORM
ABN
DEFERRED
TYPE
8. Current Medications and Instructions
1. Skin
2. Ears
3. Nose
4. Throat
5. Mouth
6. Neck
7. Breasts
9. Allergies
8. Chest
9. Lungs
10. General Appearance
10. Heart
11. Abdomen
11. Mental/Physical Status and Limitations
12. Extremities
Upper
Lower
13. Feet/Toes
12. Mobility/Ambulating Status
14. Lymph Nodes
Fully Ambulatory
Uses Walker
15. Genitalia
Uses Cane
Uses Wheelchair
16. Testes
13. Susceptibility to Hyper/Hypothermia and Related Limitations
17. Spine
18. Reflexes
19. Neurological
20. Rectal
21. Sexually Transmitted Diseases
YES
NO
22. Other:
14. Special Dietary Instructions and Recommended Caloric Intake
** Deferred , as used here, means examination considered but postponed.
Explanation of Abnormalities/Treatment Ordered
16. Other Health-Related Information or Concerns
Physician or Health Care Practitioner (Please Print)
Date
Physician Address
City
State
Zip Code
Signature
Title
Date
Date of Exam
AUTHORITY:
P.A. 218 OF 1979
The Department of Consumer and Industry Services will not discriminate against
COMPLETION :
Required
any individual or group because of race, sex, religion, age, national origin, color,
CONSEQUENCE: Violation of AFC Licensing Rules
marital status, disability, or political beliefs.
BRS-3947w (Rev. 7-96) Previous edition Rev. 1-96 ONLY may be used.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business