"Medical Appointment Information Record [mair] Form" - Delaware

This "Medical Appointment Information Record [mair] Form" is a document issued by the Delaware Health and Social Services specifically for Delaware residents with its latest version released on June 2, 2009.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Delaware Health and Social Services.

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Download "Medical Appointment Information Record [mair] Form" - Delaware

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New Castle Regional Office
Kent Regional: Office, Thomas Collins Bldg.
Sussex Regional Office, Stockley
nd
2540 Wrangle Hill Road, 2
floor
540 S. DuPont Hwy., Suite 8
Center:
Bear, DE 19701
Dover, DE 19901
26351 Patriots Way
PH: (302) 836-2100
PH: (302) 744- 1110
Georgetown, DE 19947
PH: (302) 933-3100
Delaware Health & Social Services
Division of Developmental Disabilities Services
Medical Appointment Information Record [MAIR]
Name:
MCI#:
Date:
Ht: ________ Wt: ____
____ BP: ________ P: __________ Temp:
Doctor seen:
________________ ____ Specialty:
Known Drug Allergies:
Symptoms Present:
Physical findings:
Diagnosis and Prognosis:
Restrictions:
Prescriptions & Treatment:
Return Appointment Date
Signature of Doctor:
Address:
Phone:
New Castle Regional Office
Kent Regional: Office, Thomas Collins Bldg.
Sussex Regional Office, Stockley
nd
2540 Wrangle Hill Road, 2
floor
540 S. DuPont Hwy., Suite 8
Center:
Bear, DE 19701
Dover, DE 19901
26351 Patriots Way
PH: (302) 836-2100
PH: (302) 744- 1110
Georgetown, DE 19947
PH: (302) 933-3100
Delaware Health & Social Services
Division of Developmental Disabilities Services
Medical Appointment Information Record [MAIR]
Name:
MCI#:
Date:
Ht: ________ Wt: ____
____ BP: ________ P: __________ Temp:
Doctor seen:
________________ ____ Specialty:
Known Drug Allergies:
Symptoms Present:
Physical findings:
Diagnosis and Prognosis:
Restrictions:
Prescriptions & Treatment:
Return Appointment Date
Signature of Doctor:
Address:
Phone:
MAIR Page 2
Name of Individual:
MEDICAL APPOINTMENT CHECKLIST
This form must be completed and taken on every doctor’s appointment:
The following items must accompany you on this appointment:
 Medical Appointment Information
 COR (Client Oriented Record)
Record
 Current MAR
 Physical Exam form and Standing
Medical Orders (for annual physical only)
The following questions must be answered prior to the doctor’s appointment:
What is the nature (purpose) of this appointment?
 An annual physical
 A follow up appointment

An illness
What symptoms are being experienced? How long have the symptoms been present? (Include when the
illness started, how often does it occur and how long does it last?
___________________________________________
Has this occurred before? YES NO
If yes when and what was done for it?
_____________________
What has been done for the individual to help with this condition?
Signature/Title:
Date:
At the end of the appointment, these questions should be asked of the doctor:
What care is being ordered?
___________________________
If medication is prescribed, what is the medication supposed to do? (What is the desired effect?)
_____________________
Are there any side effects that we should be concerned about?
_______________________________
Signature/Title:
Date:
PARC Approved: 11/15/04
Revised: 07/21/08, 06/02/09
Form #: 12/Admin
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