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