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Referral Source
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Preferred Name:
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Primary Care Partner:
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Relationship:
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Payee:
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Power of Attorney for Health Care:
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POA Consent Form - Date completed:
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Other Important Care Partners:
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Advance Directives:
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POLST:
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Primary Reason for Consultation:
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Dementia Diagnosis:
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Type:
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Physician who confirmed dementia diagnosis:
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Hospital System:
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Primary Health System:
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Location:
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Medical History/Date Diagnosed
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Surgical History/Date Diagnosed?
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History of Physical/Psychological Trauma:
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Cognitive Abilities:
• • •
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Copy of Medical Records:
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Lab Results:
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Pertinent Findings:
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Cognitive Findings:
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Physical Findings:
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Potential Triggers for Distress:
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Short Term Goal (s):
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Long Term Goals (s):
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