Form HFS 2305I Questionnaire and Order for Neuromuscular Electrical Stimulator (Nmes) - Illinois

Form HFS2305I is a Illinois Department of Healthcare and Family Services form also known as the "Questionnaire And Order For Neuromuscular Electrical Stimulator (nmes)". The latest edition of the form was released in February 1, 2015 and is available for digital filing.

Download a PDF version of the Form HFS2305I down below or find it on Illinois Department of Healthcare and Family Services Forms website.

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State of Illinois
Department of Healthcare and Family Services
Questionnaire and Order for Neuromuscular Electrical Stimulator (NMES)
Patient Name:
DOB:
RIN:
Make and Model of NMES:
1. Indicate the primary diagnosis necessitating a NMES:
2. Indicate any secondary diagnoses affecting the neuromuscular status:
3. What is the prognosis for recovery of muscle function after use of NMES is complete?
Excellent
Good
Fair
Poor
4. If atrophy is present, state how long it has been present, the degree, and location?
5. Specify the names and locations of the nerves/muscles that are being proposed to be stimulated:
6. Is the nerve supply intact from the brain to the spinal cord and
through the peripheral nerves to the muscles that are proposed to be stimulated?
Yes
No
7. What is the goal of the NMES?
If Yes, specify start date
No
8. Is the patient enrolled in a physical therapy program? Yes
9. Check the corresponding box if the patient has any of the following:
Pacemaker
Defibrillator
Deep brain stimulator
Cognitive impairment
Superficial metal implants in treatment area
Non-union or recent fracture in area to be stimulated
Malignancy in area to be stimulated
Active tuberculosis in area to be stimulated
Pregnancy
Skin lesion, open wound, tissue damage, devitalized tissue, extreme edema, recent bleeding, heavy scarring, thick adipose
tissue, hemorrhage, or impaired sensation in area to be stimulated
(Specify ones that are applicable):
HFS 2305I (N-2-15)
State of Illinois
Department of Healthcare and Family Services
Questionnaire and Order for Neuromuscular Electrical Stimulator (NMES)
Patient Name:
DOB:
RIN:
Make and Model of NMES:
1. Indicate the primary diagnosis necessitating a NMES:
2. Indicate any secondary diagnoses affecting the neuromuscular status:
3. What is the prognosis for recovery of muscle function after use of NMES is complete?
Excellent
Good
Fair
Poor
4. If atrophy is present, state how long it has been present, the degree, and location?
5. Specify the names and locations of the nerves/muscles that are being proposed to be stimulated:
6. Is the nerve supply intact from the brain to the spinal cord and
through the peripheral nerves to the muscles that are proposed to be stimulated?
Yes
No
7. What is the goal of the NMES?
If Yes, specify start date
No
8. Is the patient enrolled in a physical therapy program? Yes
9. Check the corresponding box if the patient has any of the following:
Pacemaker
Defibrillator
Deep brain stimulator
Cognitive impairment
Superficial metal implants in treatment area
Non-union or recent fracture in area to be stimulated
Malignancy in area to be stimulated
Active tuberculosis in area to be stimulated
Pregnancy
Skin lesion, open wound, tissue damage, devitalized tissue, extreme edema, recent bleeding, heavy scarring, thick adipose
tissue, hemorrhage, or impaired sensation in area to be stimulated
(Specify ones that are applicable):
HFS 2305I (N-2-15)
Explain any item checked in #9:
10. Is the patient capable of following directions for appropriate use of the NMES?
Yes
No
Practitioner's Signature with degree:
Date
Office Phone #:
Fax:
NPI:
HFS 2305I (N-2-15)

Download Form HFS 2305I Questionnaire and Order for Neuromuscular Electrical Stimulator (Nmes) - Illinois

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