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Referral Source:
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Preferred Name
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Age
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Address
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Primary Care Partner
|
|
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Primary Care Partner
|
Relationship
|
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Phone
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Address
|
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Email
|
|
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Payee
|
Power of Attorney for Health Care
|
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POA Consent Form - Date completed
|
Other Important Care Partners
|
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Advance Directives
|
POLST
|
|
Primary Reason for Consultation
|
|
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Dementia Diagnosis: Y/N
|
Type
|
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Physician who confirmed dementia diagnosis
|
Hospital System
|
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Primary Health System
|
Location
|
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Weight
|
Height
|
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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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Current Medications
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Allergies
|
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Cognitive Abilities
|
|
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Memory
|
Orientation
|
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Judgement & Problem Solving
|
Community Involvement
|
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Home and Hobbies
|
|
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Personal Care
|
|
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Bathing
|
Dressing
|
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Eating
|
Bowel
|
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Bladder
|
Taking medication
|
|
Shopping
|
Cooking
|
|
Cleaning
|
Laundry
|
|
Finances
|
Dialing the phone
|
|
Signs of Behavioral Distress
• • •
|
|
|
Copy of Medical Records
|
Lab Results
|
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Pertinent Findings
|
|
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Date
|
Location
|
|
Time
|
|
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Cognitive Findings
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Physical Findings
|
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Potential Triggers for Distress
|
Short Term Goal (s)
|
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Long Term Goals (s)
|
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