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Rancho Cordova Adult Day Health Care Center

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					                                            Rancho Cordova
                                          Adult Day Health Care Center
                                            10086 Mills Station Road
                                              Sacramento, CA 95827
                                      Phone: (916) 369-1113 Fax: (916) 369-1138


                                  INTAKE                  INFORMATION
Name: _________________________________________________________                                □ Male     □ Female
                               Last                              First

_______________________________________________________________________________
Address   Apt #                                                  City,                         Zip Code


Phone: (____) ______________________                  Speaks: □ English □Other______________________

DOB: _____/_____/______ Age: _____                  Marital Status: □Single □Married □Widow/er □Divorced
Lives: □ Alone □With _____________ □Unrelated or □Family IN: □House □Apartment □Board & Care
Mobility: □Independent □ Cane/Crutch □ Walker □Wheelchair □Electric W/c □ Other_____________
Problems: □ Vision_________ □ Hearing_________ □ Breathing _______ □ Uses Oxygen _______
Eligible for:     □ Medi-Cal     □ Medicare       □ Private insurance             (Please enclose a copy)

Medi-Cal Number: _________________________________                                Issue Date: ________________

Social Security Number: _______-_____-_______
Did you ever participate in another ADHC? If Yes, Name of Center: _________________________

Referred to Rancho Cordova ADHC by: ________________________________________________

Reason for Applying: _____________________________________________________________
Emergency Contacts:

1) Relative’s Name: ___________________________________ Relationship: _______________

Address: _____________________________________ Phone #: (___) ______________________

Speaks: □ English □Other_______________________ Mobile#: (___) ______________________

2) Name: ______________________________________ Relationship: ____________________

Address: _____________________________________ Phone #: (___) ______________________

Speaks: □ English □Other_______________________ Mobile#: (___) ______________________

Primary Care Physician: __________________________________________________________

_______________________________________________________________________________
Address                                                                  City,                            Zip Code

   Phone #: (____) ________________________                    Fax # :(_____) _____________________
Next PCP appointment is scheduled on: _______________________________________________
Have other MD/Specialists? □ Unknown □No □Yes _______________________________________


             STAFF: PRINT NAME                                      SIGNATURE                        DATE
                                         Rancho Cordova
                                           Adult Day Health Care Center
                                         10086 Mills Station Road
                                           Sacramento, CA 95827
                                Phone (916) 369-1113 Fax (916) 369-1138



              Consent to release medical records

Participant’s Name: __________________________________                    Date: ______________

Social Security Number: ____________________________ Date of Birth: __________

Address/Phone Number: ___________________________________________________

________________________________________________________________________

I hereby request that copies of my complete medical records be released to Rancho Cordova Adult Day
Health Care Center. I understand that Rancho Cordova ADHC may need to obtain the below checked
records and related information from physicians and other healthcare professionals in order to ensure
continuity of care and proper reimbursement. I also authorize Rancho Cordova ADHC to release
medical record and other information to others for purposes of my healthcare. A photocopy of this
authorization shall be as valid as the original.

______ Medical       ______ Psychological/Psychiatric                     _______ Neurological


Participant’s Signature: _______________________________                  Date: ______________

Participant’s Representative/Relationship: _____________________________________




Doctor’s Name: ________________________________________________

Address: ______________________________________________________

Phone/Fax Number: ____________________________________________________
                                                         Rancho Cordova
                                                           Adult Day Health Care Center
                                                         10086 Mills Station Road
                                                           Sacramento, CA 95827
                                              Phone (916) 369-1113 Fax (916) 369-1138

               PRIMARY CARE Physician’s authorization for treatment
                                    Medical history & physical exam

Participant’s Name:
                                               Last                                                     First
DOB:             /         /           Age:            Female:              Male:         Phone:


                      Street Address                                             City               State            Zip


                        Medical/Surgical/Hospitalization History:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________

                                                      PPD Test                                         Chest X-Ray
        TB                      Date Administered: _______________                           Date: ____________________
    Clearance
      done within a year        Date Read: ______________________                              □ Positive       □ Negative
                                         □ Positive      □ Negative

                                               Current Physical Exam

Wt: _____lbs Ht: ______ Temp: _____                   P______ (regular) (irregular)          Resp: ______ B/p: _____/_____

General: ______________________________________ Respiratory: _________________________________

H.E.E.N.T.: ___________________________________ Cardiovascular: ______________________________

Dermatologic: _________________________________ Gastrointestinal: ______________________________

Genitourinary: _________________________________ Neurological: ________________________________

Musculoskeletal: _______________________________ Endocrine: __________________________________

    DIET ORDER                 Choose: □ Regular diet □ No Concentrated Sweets □ No Added Salt
      Yes No          Authorization for exception to diet order 1 or 2 times per month for special events.
   DIET TEXTURE Choose: □ Regular                            □ Mechanical soft-Ground              □ Pureed
            Fall Risk? no Yes _________________________________________________________________
            Travel:  Can        Can Not … be in transit, one way, more than an hour
            Prognosis is:  Poor  Guarded  Fair  Good
Rev. 12/08                                                                                                                   Page 1 of 3
                                                    Rancho Cordova
                                                        Adult Day Health Care Center
                                                     10086 Mills Station Road
                                                        Sacramento, CA 95827
                                           Phone (916) 369-1113 Fax (916) 369-1138

                                          Current Medical Status

Participant’s Name:                                 ,                                  DOB:            /       /

There is a high potential for further deterioration & probable institutionalization
if ADHC services are not provided due to the Medical Condition of _______________________
           Diagnoses                 ICD Code                         Medication                 Dose              Frequency




Insulin Sliding Scale orders: ______________________________________________________________________
        ______________________________________________________________________________________________

       Any Allergies? ______________________________________________________________________

Medications:  Possible Mismanagement  Needs Assistance  Needs Supervision  OK to Self-medicate


       The Registered Nurse will notify you of significant changes.

               Vital signs outside of these parameters will be reported immediately:


          Blood Pressure      >180/90 or < 80/50         Pulse       < 55 or > 100     Blood Glucose       < 60 or > 250

Please indicate if you wish other parameters: _________________________________________________________

     Finger Stick Blood Glucose Testing for patients with:
SQ Insulin administered at the ADHC will be routinely checked each visit, unless otherwise ordered: _________
_____________________________________________________________

NIDDM & IDDM who do not receive SQ injections by the nurses are checked/ Only 1x/wk & PRN s/s of Hypo/Hyperglycemia,
unless otherwise ordered: ___________________________
     Authorization of the following PRN Standing Orders:                Yes        No
            Tylenol 500mg 1-2 tab PO PRN every 4 hrs fever ≥100 or pain    □           □
            Mylanta 30cc PO PRN every 4 hrs heartburn/gastric upset        □           □
            NTG 0.4mg SL PRN chest pain:
                 1tablet every 5 min x 3 doses; Call 911 if not relieved   □           □
  Rev. 12/08                                                                                                               Page 2 of 3
                                                         Rancho Cordova
                                                            Adult Day Health Care Center
                                                         10086 Mills Station Road
                                                            Sacramento, CA 95827
                                              Phone (916) 369-1113 Fax (916) 369-1138


Participant’s Name:                                     ,                                      DOB:          /         /


                            PRIMARY CARE PHYSICIAN CERTIFICATION FOR ADHC

I certify that the patient is (has):
1) A medical condition (physical/mental disability) that requires treatment/rehabilitative services prescribed by a physician

Please describe needed treatment modalities (e.g. ADHC services, education, medical services, physical/occupational
restorative/maintenance services): ________________________________________________________________________

____________________________________________________________________________________________________


2) Physical/Mental impairments that handicap ADLs, but not serious enough to require 24-hour institutionalization

Please describe specific impairments in ADLs, (such as eating, dressing, grooming, transferring, mobility): ______________

_____________________________________________________________________________________________________


3) A reasonable expectation that preventative services (ADHC) will maintain or improve present level of physical/mental
functioning

Please describe specific functions and services (e.g. ADHC services) needed: _____________________________________

___________________________________________________________________________________________________


4) A high potential for further deterioration and probable institutionalization if ADHC services were not available

Please describe risks/events (e.g. falls, isolation, loss of cognitive stability) that might increase the patient’s chance of being placed in
higher/intensive/long-term care setting:

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

                           ♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦


_______________________________________________________________________________________
(Print Name)  Primary Care Physician                 Signature                      Date


Street Address                                    City, State, Zip                         Phone #




Rev. 05/09                                                                                                                          Page 3 of 3

				
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