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Introduction, Confirm Demographics
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Preferred Post-Hospital Followup Plan
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Other Followup plan
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Additional Contact Info
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Preferred method of communication
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May we text you?
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Phone number to be used for texting
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May we email you?
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Email address that may be used for communication with you:
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Closest Contacts:
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Closest contacts (with phone #s and/or addresses)
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Closest contacts (with phone #s and/or addresses)
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Closest contacts (with phone #s and/or addresses)
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Closest contacts (with phone #s and/or addresses)
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Alternate addresses (other locations you may stay from time to time)
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Alternate addresses (other locations you may stay from time to time)
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Preferred Language(s) Spoken
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Preferred Interpreter for medical conversations
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Medical & Social Services
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Do you have a PCP who knows you and can take care of your medical problems well?
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Primary Care Doctor (and contact info)
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When you feel sick, can you get an appt as quickly as you want?
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Do you currently have an appt scheduled to see your PCP in the next 1-2 weeks?
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Have you missed doctor visits in the last 6 mos?
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If yes, why did you miss doctor's appts?
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"Other" reasons why pt misses doctor's appts:
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Are there any doctors/offices that you never miss? if so, how do they help you?
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Are you being followed by any specialists?
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Specialists involved in care
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Other Specialists involved in care:
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Are you receiving any in-home services?
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List all in-home services
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Do you have difficulty taking your medications as prescribed?
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If yes, please indicate all the reasons that apply
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"Other" reasons why pt misses doses of meds:
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Preferred Pharmacy (include location)
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Do you have problems obtaining your medications as ordered
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Do you understand how to take your medications after you get home from this hospitalization?
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Comments about D/C meds
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Do you need any medical equipment delivered to your home when you are discharged from the hospital?
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What arrangements have been made for medical equipment/supplies?
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On a scale of 0-10, how confident are you that you can manage your health at home after discharge?
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Why did you give yourself a score lower than 10?
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Needs Assessment
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Do you miss meals or worry about missing meals bc of lack of food for any reason?
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What are your barriers to food access?
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Have you been homeless or worried about being homeless in the last year?
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Housing concerns:
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May we contact Social Services to help you with any of these problems?
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Do you have any problems with addiction?
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Comments:
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Are you interested in help with problems of addiction?
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What kind of addiction assistance are you interested in?
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