Silverthorne Adult Medical Day Program

23 Geremonty Dr.

Salem, NH 03079  (603) 893-4799

 

HISTORY AND PHYSICAL EXAMINATION

 

Name:______________________________________DOB________________________

 

Diagnosis:_______________________________________________________________

 

PMH:___________________________________________________________________

 

_______________________________________Allergies:_________________________

 

BP:_________Pulse:__________Weight:__________Vision:_________Hearing:______

Mental Status:__________________ENT:__________________Neck:_______________

 

Chest:___________Abdomen:_____________Breasts:____________Genitalia:________

 

Musculoskelital:_________________________Neurological:______________________

 

Skin:___________________________________________________________________

 

Incontinence: Bladder            Yes      No                   Bowel: Yes     No       (Please Circle)

 

Recent tests or x-rays:______________________________________________________

 

Dates of last: Flu Vaccine:____________Pneumovax_________________Tetanus (TDaP)_____________

 

Medical Goals:___________________________________________________________

 

Are you aware of the patient having any type of advanced directive for health care?

___________YES___________NO.                              Has it been activated? Yes_______NO______

 

 

I find no evidence of communicable disease in this patient at the time of this examination nor of any contraindication for participation in an Adult Day Care Program.

 

 

MD signature__________________________________Date_______________________

 

Printed name of MD_______________________________________________________