"Patient History Form - Esph"

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MRN:
SURNAME:
OTHER NAMES:
PATIENT HISTORY FORM
DOB:
SEX:
AMO:
(Affix Addressograph Label Here - Hospital use only)
To be completed by Patient or Carer.
Please PRINT clearly. Your responses are valuable in planning your admission and caring for you during your stay.
ADMISSION DETAILS
Please specify the reason for your admission
NO
YES
COMMENTS OR FURTHER INFORMATION
Is this admission due to a past or present injury?
Cause of Injury:
Place:
Date
/
/
Have pathology/blood test/autologous blood been taken for
Pathologist:
this admission?
Results with:
Have X-rays been taken for this admission?
With patient
With doctor
What is your: Height .................cms
Weight .................Kgs
Blood Group (If Known) ...........................
MEDICATIONS
Have you recently taken blood thinning/arthritis medication
Name of Medication:
(Aspirin Based)?
Have you been instructed to cease this medication?
Date last taken
/
/
or still taking
Yes
Have you taken any steroids or cortisone tablets/injections in
Name of Medication
the last 6 months?
Date last taken
/
/
or still taking
Yes
Are you taking any other prescription or non-prescription
MEDICATION
FOR TREATMENT OF
FREQUENCY
DAILY DOSE
medication? List the medications you currently take (include
name of medication). Please bring all medications you are
currently taking with you on admission in the original packaging
GENERAL MEDICAL CONDITION
SPECIFY DETAILS
Type 1
Type 2
Unsure
Diabetes
Managed by
Diet
Tablets
Insulin
Cancer
Site:
Stroke
Date:
/
/
Residual problems
High blood pressure
Heart attack/chest pain/angina
Date:
/
/
Palpitations/irregular heart beat/heart murmur
Pacemaker
Make
Model
Last checked
/
/
Prosthetic heart valve
Type
Rheumatic Fever
Tendency to bleed/bloodclots/bruise easily
Arthritis
Asthma/bronchitis/pneumonia/hayfever
Liver disease/hepatitis (Specify type A, B, C)
Kidney/bladder problems
Hiatus hernia/gastrointestinal ulcers/bowel disorder
Thyroid problems
Epilepsy/fits/febrile convulsions
Depression/dementia/other mental illness
Migraines
Eye disease
Female patients could you be pregnant?
Number of weeks:
Impairment e.g. vision, hearing, mobility
History of pressure injuries
15
MRN:
SURNAME:
OTHER NAMES:
PATIENT HISTORY FORM
DOB:
SEX:
AMO:
(Affix Addressograph Label Here - Hospital use only)
To be completed by Patient or Carer.
Please PRINT clearly. Your responses are valuable in planning your admission and caring for you during your stay.
ADMISSION DETAILS
Please specify the reason for your admission
NO
YES
COMMENTS OR FURTHER INFORMATION
Is this admission due to a past or present injury?
Cause of Injury:
Place:
Date
/
/
Have pathology/blood test/autologous blood been taken for
Pathologist:
this admission?
Results with:
Have X-rays been taken for this admission?
With patient
With doctor
What is your: Height .................cms
Weight .................Kgs
Blood Group (If Known) ...........................
MEDICATIONS
Have you recently taken blood thinning/arthritis medication
Name of Medication:
(Aspirin Based)?
Have you been instructed to cease this medication?
Date last taken
/
/
or still taking
Yes
Have you taken any steroids or cortisone tablets/injections in
Name of Medication
the last 6 months?
Date last taken
/
/
or still taking
Yes
Are you taking any other prescription or non-prescription
MEDICATION
FOR TREATMENT OF
FREQUENCY
DAILY DOSE
medication? List the medications you currently take (include
name of medication). Please bring all medications you are
currently taking with you on admission in the original packaging
GENERAL MEDICAL CONDITION
SPECIFY DETAILS
Type 1
Type 2
Unsure
Diabetes
Managed by
Diet
Tablets
Insulin
Cancer
Site:
Stroke
Date:
/
/
Residual problems
High blood pressure
Heart attack/chest pain/angina
Date:
/
/
Palpitations/irregular heart beat/heart murmur
Pacemaker
Make
Model
Last checked
/
/
Prosthetic heart valve
Type
Rheumatic Fever
Tendency to bleed/bloodclots/bruise easily
Arthritis
Asthma/bronchitis/pneumonia/hayfever
Liver disease/hepatitis (Specify type A, B, C)
Kidney/bladder problems
Hiatus hernia/gastrointestinal ulcers/bowel disorder
Thyroid problems
Epilepsy/fits/febrile convulsions
Depression/dementia/other mental illness
Migraines
Eye disease
Female patients could you be pregnant?
Number of weeks:
Impairment e.g. vision, hearing, mobility
History of pressure injuries
15
PREVIOUS OPERATIONS / PROCEDURES / ANAESTHETIC DETAILS
Have you had previous operations, please list dates and operations performed:
Date
/
/
Date
/
/
Date
/
/
Date
/
/
Date
/
/
Date
/
/
NO
YES SPECIFY DETAILS
Have you or anyone in your immediate family ever
Details of reaction
had a reaction to an anaesthetic? eg. malignant hyperthermia
Have you ever had a blood transfusion?
Details of any reaction
PROSTHESIS / AIDS / OTHERS
Glasses/Contact Lenses
Hearing aid or other hearing appliance
Body Piercing
Dentures/Caps/Crowns/Loose Teeth
Artificial joints or limbs
Metal plates/pins
LIFESTYLE
Have you ever smoked?
Daily amount
or date ceased
/
/
Do you drink alcohol?
Daily amount
Do you use recreational drugs?
Type Daily amount
Do you require a special diet?
Type of Diet
Do you exercise?
< 30mins per day
30mins per day
30mins per day plus aerobic activity 3 times per week
Do you require an interpreter?
Language spoken at home
Do you have someone to interpret for you?
Name of Person
Have you a fear of falling or have fallen within the last 6 months?
Do you use mobility aids
Yes
No
Have you experienced fainting or dizziness in the last 6 months?
ALLERGIES
Do you have any allergies to medications, food, sticky plaster,
Specify Details and Reaction:
latex/rubber (e.g. balloons, gloves) or other substances?
INFECTION RISK
Have you travelled to a country with a health alert in the
last 7 days
Do you have a fever and/or respiratory symptoms eg. cough,
sore throat, runny nose
Have you had recent contact with patient/s diagnosed with
Acute Respiratory Infections or Acute Respiratory Ilness in the
last 7 days (Seasonal of Pandemic) eg. SARs/H5N1 Influenza,
either overseas or in Australia, within 7 days of onset of
symptoms
Have you travelled to areas of high prevalence for Acute
Respiratory Infections or Acute Respiratory Ilness in the last 7
days (Seasonal of Pandemic) eg. SARs/H5N1 Influenza, either
overseas or in Australia, within 7 days of onset of symptoms
Have you ever had MRSA, VRE or ESBL
Do you have any wounds or breaks on your skin
Do you have any other conditions or infections
Have you had vomiting and diarrhoea in the past 48 hours
QUESTIONS RELATING TO
CREUTZFELDT JAKOB DISEASE
Have you had a dura mater graft between 1972 - 1989?
Do you have a family history of 2 or more relatives with CJD or
other unspecific progressive neurological disorder?
Have you received human pituitary hormones (growth
hormones, gonadotrophins) prior to 1985?
Has the patient suffered from a recent progressive dementia
(physical or mental), the cause of which has not been diagnosed?
16
MRN:
SURNAME:
OTHER NAMES:
PATIENT HISTORY FORM
DOB:
SEX:
AMO:
(Affix Addressograph Label Here - Hospital use only)
To be completed by Patient or Carer.
Please PRINT clearly. Your responses are valuable in planning your admission and caring for you during your stay.
DISCHARGE PLANNING
This information is necessary in order to help you plan a safe return to home after discharge. ALL patients to complete
Are you over 80 years of age?
Do you live alone?
I have no one to look after me after discharge.
or, name of person
Relationship
Are you solely responsible for the care of another person at home?
Do you currently receive community support services?
Do you require assistance with any aspect of day to day living?
Details
Where do you plan to go after discharge?
How will you get there?
Name of person completing form:
Relationship:
Date:..../......../......
NURSES USE ONLY
RISK SCREENING
NO
YES
COMMENTS
NURSING NOTES
Completed and attached
Fall risk screen required (day surgery patients who have been
Refer to Policy
identified as a risk and all overnight patients)
Yes
No
Completed and attached
Pressure Injury risk screen required (day surgery patients who
have been identified as a risk and all overnight patients)
Yes
No
Patient history form reviewed by Pre-admission / Admitting nurse
Yes
No
Name of admitting nurse:
Date:
Signature:
Designation:
Time:
Patient history form reviewed by DSU / Ward Staff
Yes
No
Name of DSU / Ward nurse:
Date:
Signature:
Designation:
Time:
CLINICAL / PRE-ADMISSION NOTES
17
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