PATIENT HEALTH ASSESSMENT

Patient Name: Date of Admission or Procedure:

Abington Memorial Hospital

PATIENT INSTRUCTIONS: Please complete all sections on each page or have someone complete it for you. Answer by when appropriate. Please bring this completed form with you to your Preadmission Center appointment. PERSONAL INFORMATION Patient Name: Date of Admission or Procedure: Admitting Physician or Surgeon: Person providing information: Relationship: Language spoken: Is an interpreter needed? Name and phone # of interpreter: Do you have a living will? YES NO YES UNKNOWN NO Phone # English YES Other NO Date:

Do you have a durable power of attorney for healthcare? If yes: Name

(If yes to above question, please bring a copy to the hospital on admission.) Are you an Organ Donor? Primary Physician: REASON FOR ADMISSION (please describe): YES NO UNKNOWN Phone #

ALLERGIES NONE MEDICATIONS LATEX FOOD OTHER

List Allergies and Reactions:

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PATIENT HEALTH ASSESSMENT

Patient Name: Date of Admission or Procedure:

Abington Memorial Hospital

Current weight *Weight 1 yr. ago Alcohol Use: Denies beer Drinks socially Tobacco use: Denies cigarettes Current cigars Current liquor

Actual Height Past wine per day Past pipe

Estimated

Other: per week

chew

How many cigarettes do you smoke a day? Do you have a cigarette within one hour of awakening? Illicit drug use: Never Past Now Not applicable Peritoneal Dialysis Dialysis YES NO

Are you undergoing any treatments: Chemotherapy Other Immunizations: Tetanus/Yr Other/Yr Radiation

Flu vaccine/Yr

Pneumonia vaccine/ Yr

Medications taken regularly (Prescription, over the counter, home remedies): Name of medication Dose and Frequency

None

Herbal preparations:

Have you had any changes in medication in the past 30 days?

YES

NO

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PATIENT HEALTH ASSESSMENT

Patient Name: Date of Admission or Procedure:
RESPIRATORY/LUNGS: Asthma Cancer Chronic bronchitis Chronic cough/cough with mucus Emphysema VASCULAR/HEART: Abnormal EKG Blood clots Cancer Chest pain Chest Pressure Circulation problems Fainting episodes NEUROLOGICAL/BRAIN/ SPINAL CORD: Alzheimers Back pain Cancer Difficulty learning Difficulty speaking Difficulty with balance Dizziness No problems Loud snoring Pneumonia Positive TB test Recent cold or flu Shortness of breath No problems Heart attack Heart blockage Heart murmur High/Low blood pressure Internal defibrillator Irregular heart beat Pacemaker

Abington Memorial Hospital

Sleep apnea TB Tracheotomy Wheezing

Palpitations Phlebitis Swelling of feet/ankles/legs Valve disorder Varicose veins

No problems Fainting Frequent headache Memory problems Mini stroke Neck pain Numbness Paralysis of arm/leg L R Seizures Severe headaches Speech slurred Stroke Tingling of arm/leg Weakness L R

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PATIENT HEALTH ASSESSMENT

Patient Name: Date of Admission or Procedure:
GASTROINTESTINAL/BOWEL/DIGESTIVE: Bowel obstruction Cancer Chronic diarrhea Cirrhosis of liver Colitis Colostomy Constipation MUSKULOSKELETAL: Arthritis Artificial joint(s) Cancer Fracture Gout ENDOCRINE: Cancer Diabetes Hormone disorder Low blood sugar Thyroid disorder Crohns disease Excessive burping Heartburn Hemorrhoids Hepatitis Hiatal hernia Iliostomy No problems Lupus Muscle disease Muscle weakness Osteoporosis Pins, Rods, Internal Fixators No problems

Abington Memorial Hospital

No problems Irritable bowel Jaundice Pancreatitis Rectal bleeding Nausea/vomiting Ulcer

Sciatica TMJ pain or jaw disorder

BLOOD: Anemia Blood transfusion Cancer Easy bruising Frequent nosebleeds Immunosuppressed

No problems

PSYCHIATRIC: Anger Anxiety Dementia Depression

No problems Eating disorder Hallucinations Manic depression Mood swings Schizophrenia Suicide attempt

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PATIENT HEALTH ASSESSMENT

Patient Name: Date of Admission or Procedure:
SKIN: Bed sore Non-healing sores Rashes URINARY/REPRODUCTIVE: Blood in urine Burning Cancer Difficult urination Frequent urination Infections Kidney stones No problems Shingles Skin Cancer Skin disorder No problems Loss of control Pain Prostate Problems (males) Self Catheterization Sexually transmitted diseases Urinary catheter (presently) Ureterostomy

Abington Memorial Hospital

Ulcerations

Females: Last menstrual period: Pregnant: Yes No Unsure

Weeks pregnant: Due date: Breast feeding

EYES/EARS/NOSE/THROAT: Blind Cancer Cataracts Contact lenses Corneal Implants OPERATION PROCEDURES: List all surgeries and approximate dates:

No problems Deaf Deviated septum Glasses Glaucoma Hearing aids None Hearing impairment Ringing in ears Sinus problems TTY needed

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PATIENT HEALTH ASSESSMENT

Patient Name: Date of Admission or Procedure:
ANESTHESIA: Never had anesthesia You or a blood relative had unexplained fever right after surgery Difficult intubation, problems with airway/breathing Difficulty waking up from anesthesia You required ventilator after surgery Blood relative required ventilator after surgery Severe nausea after surgery NUTRITION: Special Diet: Cardiac Chopped/soft Cultural-specific diet No problems No restrictions Diabetic Feeding tube Fluid restriction No 1-5 lbs (1 point) 6-10 lbs (2 points) 11-15 lbs (3 points) Have you been eating poorly because of a decreased appetite? No (0 points) Yes (1 point) Kosher No problems

Abington Memorial Hospital

DENTAL HISTORY: Braces Bridges Broken teeth Caps Implants Loose teeth

No problems

Dentures: Upper: Full Lower: Full Partial Partial

Thick It Vegetarian

Low salt diet Renal Unsure Yes

Have you lost weight recently without trying? If yes, how much weight have you lost?

>15 lbs (4 points) Unsure (2 points)

Total screening score:

ADJUSTMENT TO ILLNESS: Request for Support or Counseling: Please check all those that apply. Coping strategies Family issues Medical advocate Pastoral Care Psychiatric crisis Social Work Support group Work issues

Are there any cultural, religious, or spiritual beliefs that we need to know in order to provide care for you? Yes Are there any spiritual needs that we need to address while you are in the hospital?
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No No

Yes

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PATIENT HEALTH ASSESSMENT

Patient Name: Date of Admission or Procedure:
DISCHARGE/DISPOSITION: Living Arrangements Patient lives in: Apartment House Personal care facility Skilled nursing facility Long term care facility SELF CARE:

Abington Memorial Hospital

No problems

Needs help with: Bathing Cooking Dressing Eating Homemaking Toileting

Patient lives with: Alone Adult Child Parent Private aide Name of Person: Sibling Spouse Friend/Other

Place patient is planning to go at discharge: Home Unknown

Preadmission Residence

Person Responsible for transportation home: Name of Person:

Phone #

Phone #

Support available at home: Full-time Part-time Undetermined No help available

Has 24-hour companion at home: Family Friend Spouse

Yes

No

Attendant (private aide)

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PATIENT HEALTH ASSESSMENT

Patient Name: Date of Admission or Procedure:
CURRENT HOME CARE SERVICES/EQUIPMENT: Day Care Hospice Name of Agency: Patient Uses: Cane Commode Grab bar MOBILITY/ACTIVITY: Ambulatory / Walks well alone Supervision: Minimal Moderate Maximum Patient is bed bound Independent Hospital bed Oxygen Therapy Tub bench Wheelchair Name of company: Nursing Care Occupational Therapy

Abington Memorial Hospital

Not applicable Physical Therapy Social Worker Speech Therapy

Requires assistance Prosthetic device:

Assistive Devices Used: Cane Crutches Hemicane Walker Wheeled walker Wheelchair

Communications level/Devices: Normal Impaired

Please state anything else you think we should know:

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