"Physical Examination and Medical History Form - Vinland National Center"

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Vinland National Center
Committed to full lives for people with disabilities.
PHYSICAL EXAMINATION AND MEDICAL HISTORY
Page 1 of 2
Participant name: _______________________________________________DOB:__________ Date of exam: __________________
***These items must be answered***
Current medical diagnoses: ________________________________________________________________________________
Mental health diagnoses:___________________________________________________________________________________
Current Medications: _____________________________________________________________________________________
Check box if no medications ____________________________________________________________________________
Past Medical History and Review of Systems; check if has or has had any of the following:
Requires 24-hour skilled nursing
Yes
No
Appears free of communicable disease
Yes
No
(if no, explain)_____________________________________________________
Mantoux (test is required for admission)
Date given: _____________________________________________
Date read/results:
___________________________________________
(must be within 30 days prior to admission)
Self preservation skills: In an emergency (fire alarm, gas leak, etc) is this person capable of taking appropriate action (getting
out of the building) for self preservation? Yes
No
Diet:
regular
mechanical
pureed
diabetic
Hepatitis, liver problem
Allergies: (medications, foods, insects)_______________________________________________
Vinland Standing Orders approved for PRN medications:
Yes
No
Note: please see enclosed sample copy of Vinland’s Standing Orders)
Exceptions: _____________________________________________________________________
History of MRSA? Yes No
Past medical history:
Review of systems
(current or recent):
Kidney disease
TBI or Head injury with LOC
Chronic cough or hemoptysis
Pancreatitis
Fractures
Night sweats
HIV or AIDS
Thyroid problems
Ear, nose, throat problems
Sexually transmitted disease
Asthma or difficulty
Swollen lymph nodes
Diabetes
breathing
Chest pain
Seizures
Emphysema/COPD/other
Shortness of breath
Cancer
chronic lung disease
Stomach problems
Bleeding disorder or sickle
TB or lived with anyone with
Constipation or diarrhea
cell
Hypertension
Hemorrhoids, black or
Suicide attempt
Heart disease
bloody stools
Mental health hospitalization
Stroke
Muscle, bone or joint
GERD or ulcers
problems
Hernia or rupture
Skin problems/Open wounds
Comments on positive responses from PMH and ROS above:
Past surgeries (year and procedure)
Hospitalizations (year and reason)
For office use only
Vinland National Center
Committed to full lives for people with disabilities.
PHYSICAL EXAMINATION AND MEDICAL HISTORY
Page 1 of 2
Participant name: _______________________________________________DOB:__________ Date of exam: __________________
***These items must be answered***
Current medical diagnoses: ________________________________________________________________________________
Mental health diagnoses:___________________________________________________________________________________
Current Medications: _____________________________________________________________________________________
Check box if no medications ____________________________________________________________________________
Past Medical History and Review of Systems; check if has or has had any of the following:
Requires 24-hour skilled nursing
Yes
No
Appears free of communicable disease
Yes
No
(if no, explain)_____________________________________________________
Mantoux (test is required for admission)
Date given: _____________________________________________
Date read/results:
___________________________________________
(must be within 30 days prior to admission)
Self preservation skills: In an emergency (fire alarm, gas leak, etc) is this person capable of taking appropriate action (getting
out of the building) for self preservation? Yes
No
Diet:
regular
mechanical
pureed
diabetic
Hepatitis, liver problem
Allergies: (medications, foods, insects)_______________________________________________
Vinland Standing Orders approved for PRN medications:
Yes
No
Note: please see enclosed sample copy of Vinland’s Standing Orders)
Exceptions: _____________________________________________________________________
History of MRSA? Yes No
Past medical history:
Review of systems
(current or recent):
Kidney disease
TBI or Head injury with LOC
Chronic cough or hemoptysis
Pancreatitis
Fractures
Night sweats
HIV or AIDS
Thyroid problems
Ear, nose, throat problems
Sexually transmitted disease
Asthma or difficulty
Swollen lymph nodes
Diabetes
breathing
Chest pain
Seizures
Emphysema/COPD/other
Shortness of breath
Cancer
chronic lung disease
Stomach problems
Bleeding disorder or sickle
TB or lived with anyone with
Constipation or diarrhea
cell
Hypertension
Hemorrhoids, black or
Suicide attempt
Heart disease
bloody stools
Mental health hospitalization
Stroke
Muscle, bone or joint
GERD or ulcers
problems
Hernia or rupture
Skin problems/Open wounds
Comments on positive responses from PMH and ROS above:
Past surgeries (year and procedure)
Hospitalizations (year and reason)
For office use only
Vinland National Center
PO Box 308
Loretto, Mn 55357
Phone: 763-479-3555
Fax: 763-479-4372
E-Mail: vinland@vinlandcenter.org
VINLAND CHEMICAL DEPENDENCY PROGRAM HISTORY & PHYSICAL
Page 2 of 2
Temp
BP
Pulse
Resp.
SaO
Height
Weight
2
Physical Exam: (Check appropriate box, provide explanation for abnormal finding below):
NL
ABN
NL
ABN
Head
Head atraumatic
Back
Inspection
Eyes
Pupils, EOM
Conjunctiva
ABD
Bowel sounds
Ears
TM’s, external ear canal
Tenderness
Masses/hernia
Nose
Nares
Organomegaly
Mouth
Throat
Pharynx
Extremities
Inspection
Joints
Neck
Tenderness
Strength
Range of Motion
Feet
Thyroid
Lymph nodes
Neurologic
Orientation
Mood
Respiratory
Breath sounds
Gait
Chest wall symmetry
Cranial nerves grossly intact
A/P diameter
Reflexes: Achilles/Patella
Gross motor
Cardiac
Rate and rhythm
Tremor
Heart sounds
Carotids if over 50
Skin
Inspection
Peripheral pulses
(Rashes, open wounds?)
Describe abnormal findings from physical examination:
Name of examining physician/practitioner (please print): _____________________________________________________________
Clinic name: __________________________________________________________________________________________________
Clinic address: ________________________________________________________________________________________________
Physician/Practitioner phone: __________________________________
fax: _________________________________
Physician/Practitioner signature/title: _________________________________________________ Date: (mm/dd/yyyy)__/__/____
Pre-admission H & P
Phone: 763-479-3555
3675 Iduhapi Road
Fax: 763-479-2605
P.O. Box 308
Website: VinlandCenter.org
Loretto, MN 55357-0308
STANDING ORDER FOR OVER THE COUNTER
MEDICATIONS
NAME _____________________________ ALLERGIES ____________________
The following maybe given on a PRN basis. Medications contraindicated will be noted by the
physician. Equivalent generic or store brands may be used. Seasonal supplies will be
stocked PRN. Follow all instructions listed. Chart medications administered on the Medication
Sheet. Write the reason for giving and the participant's response to the medication in the Health
Progress Notes.
FEVER/PAIN/MENSTRUAL CRAMPS
Notify the nurse of a temperature above 100 degrees and pain not relieved by medication.
Tylenol (Acetaminophen) 500 mg Extra Strength tablets (1-2 tablets) q 6 hrs prn NOT TO
EXCEED 8 TABLETS IN 24 HOURS
Tylenol Elixir (Acetaminophen Elixir) 4 tsp. (650 mg) (o) q 4 hrs prn or
Ibuprofen 200 mg (o) 1-2 tablets or capsules q 4 hrs prn; do not exceed 6 tablets in 24 hrs.
COLD/DISCOMFORT FROM COLD/SORES THROATS
Notify the nurse of temperature above 100 degrees or below 97.6 degrees; if participant has been
exposed to strep infection, persistent cough, earache chest pain or congestion; skin rash; or any
symptom lasting more than 3 days.
Claritan (Loratadine) 1 tab every 24 hours X 3-5 days PRN 10mg tablets for congestion.
Robitussin DM (Dextromethorphan and Gualfensin) (o) 2ttsp. q 4 hrs prn cough. Do Not
exceed 6 doses in 24 hrs.
Chloraseptic Lozenges (o) for sore throat. Follow directions on package.
CONSTIPATION
Notify the nurse if participant has gone three days without having a BM. Notify the nurse if
participant does not have a BM within 24 hours after giving laxative. Under direction of the
nurse or MD may give:
Milk of Magnesia (o) 2 tablespoons qd prn. (Usually given at HS)
DIARRHEA
Notify the nurse. Avoid milk products. Give clear liquids. Give clear liquids such as cola, 7-up,
Gatorade, Kool-Aid, Popsicle's, tea or apple juice. Under direction of nurse or MD may give:
st
Imodium (Loperamide) 2 mg (o) 2 capsules or tablets after 1
loose bowl movement, followed
by one tablet or capsule after subsequent loose bowel movement. No more than 4 caps per day.
Do not use for more than 2 days.
INDIGESTION/NAUSEA/HEARTBURN
Notify nurse or symptoms unrelieved by medication or if vomiting occurs.
Maalox (Alumina and Magnesia) 15 cc (o) q 3-4 hrs prn
MINOR WOUNDS AND BURNS
Notify the nurse if area appears infected; if there is a question about the need for stitches; or if
burned area is blistered or skin broken.
Bacitracin Ointment (T) apply to wound 1 to 3 times a day prn. Do not use on a deep or
puncture wounds or burns unless directed by physician.
RELIEF OF MILD SUNBURN OR ITCHING
(due to poison ivy/oak, insect bites or other minor skin irritation)
Notify nurse before applying to a rash. Do not to blistered, raw or oozing skin. Discontinue use
and notify MD if burning sensation occurs, rash develops, or condition persists after 7 days.
Apply Calamine Lotion (T) apply liberally 3-4 times a day prn. Shake well. Clean area with
soap and water and dry before each application.
RASHES/SKIN IRRITATIONS/SKIN INFLAMMATION
Notify the nurse prior to use. Notify MD if condition worsens or symptoms persist after 7 days.
1% HC Cream (T) apply 3-4 times a day prn. Do not apply to an area larger than 10" by 10"
unless directed by MD. Avoid eye, eyelid and oral contact.
ATHLETE'S FOOT
Refer to MD if not improved after 2 weeks. Participant should was feet daily and dry well.
Encourage use of clean, white cotton socks.
Micatin (Miconazole) (T) apply cream sparingly and massage in well between toes and affected
areas in the morning and at bedtime.
DANDRUFF
Notify the nurse at next visit if there are severe or patchy areas on the scalp.
Selsun Blue Shampoo (Selenium Sulfide) (T) use 1-2 times per week for dandruff. Shake well
before use, lather, rinse and repeat. Rinse well and avoid getting into eyes.
DRY SKIN AND LIPS
Notify the nurse if areas do not respond to treatment in 5 days or if rash develops.
May use non-medicated hygiene/grooming products as indicated or as directed by the nurse.
Carmex (T) apply to lips 2-4 times/day prn for chapping, fever blisters, or cold sores.
PREVENTION
Sunburn - may use any sunblock with a minimum Sunburn Protection Factor of 15. Follow
directions on the bottle.
Insect Bites - May use insect repellent as directed on container. Use insect spray with DEET to
help protect from Deer Ticks
EPI PENS – If participant identifies self as allergic to bee strings an EPI pen will be available.
OTHER
Benadryl 25-50 mg q 6 h PRN WITH NURSE DIRECTION
Physician Signature______________________________ Date _________________________
S:\Forms – Medical Office\Standing Order for Over the Counter Medications – 11/2010
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