general information patient database

PATIENT DATABASE Version 12.09 Copy to Chart

Each page must have pt. ID label

GENERAL INFORMATION PATIENT DATABASE

Preferred Name:

Why are you in the hospital (chief complaint)? _____________________________________

How can we provide “Very Good” care for you during your hospital visit? ______________________________________

If you have been hospitalized before, did you determine a specific Resuscitation/Code status ?

Full resuscitation/code No resuscitation/code Other

Do you have an Advanced Directive (living will, etc.)? Yes No

If yes, is it an Advance Directive Living Will Durable Power of Attorney Other

Location of Legal Healthcare Directive: Copy obtained from previous record Copy placed on paper chart

Family to bring in copy from home Scanned into EMR Unable to obtain copy

If you do not have an advanced directive, would you like assistance in developing one?

Yes No

Information Given By: ___________________________________

Name of information source (if not patient): ______________________________________

Primary Language Spoken: _______________________________________________

Do you have a good understanding of the English language? Yes No

Do you need an interpreter? Yes No Name of interpreter:

Interpreter: Offered Refused Patient Request Family / friend as interpreter Unable to Provide appropriate interpreter

Unable to provide appropriate interpreter reason:

Family Information:

Emergency contact / spokesperson: __________________________ Relationship: ___________________________

Preferred phone number: ( ) ______________ Alternative phone number: ( ) ____________

Legal Guardian: ____________________________________

Legal guardian relationship to patient: ___________________________________

Child resides with whom: _____________________________________________

Provider Information:

Who is your primary care physician? ______________________ Non-Sharp affiliated PCP: _______________________

Date of last visit / exam: _____ / _____ / ______Other Provider/Specialty:_________________________________

Special Requests:

Do you have any special requests regarding visitors? Yes No

If so please describe: __________________________________________________________________________

ALLERGIES

Are you allergic to latex or rubber? Yes No

Are you allergic to iodine, X-ray dye, or shellfish? Yes No

Do you have a tape allergy? Yes No

Height: Patient stated body weight:

MEDICAL HISTORY: Please check all that apply to your past medical history Check the None box if you have no problems in that area.

*Anesthesia Comment

Have you had any problems with previous anesthetics? If so, please describe:

Yes No

Have any of your blood relatives had unusual reactions to anesthesia? If so, please describe:

Yes No

Have you had any problems with difficult intubation? If so, please describe

Yes No

Nausea/Vomiting Yes No

Other anesthesia issues Yes No

Airway / Head/ & Neck None Airway note

Chronic ear infections Yes No

Dentures / partials Yes No

Difficulty fully opening mouth Yes No

False eye Yes No

Loose or chipped teeth Yes No

Permanent crowns/veneers / caps Yes No

Other airway/head & neck issues Yes No

*Cardiac / Heart Cardiac note If patient answers yes to “chest pain / angina” complete the chest pain algorithm section Aneurysm (where)

None

Yes No

Cardiac note

*Angioplasty (date) Yes No

Blood vessel clots (where/date) Yes No

*Chest pain or angina (date) Yes No

Congestive heart failure Yes No

Gestational hypertension Yes No

*Heart attack (date) Yes No

*Heart bypass (date) Yes No

Heart failure (date) Yes No

Heart murmur Yes No

Heart valve problem Yes No

*High blood pressure Yes No

High cholesterol Yes No

Palpitations/irregular heart beat Yes No

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Poor circulation Yes No

Short of breath at rest – cardiac Yes No

Short of breath with exertion Yes No

*Stent (date) Yes No

*Other cardiac/heart issues Yes No

*Do you have a Pacemaker or AICD both?

Pacemaker Information available? Yes Unknown Asked patient to bring in Other

When was Pacemaker/AICD last placed? ___________________

Date last Interrogated______________Make___________ Model_____________Cardiologist____________________

*Exercise tolerance – Do you get short of breath after walking?

Yes No Exercise note

Up one flight of stairs? Yes No

*Up two flights of stairs? Yes No

One level block? Yes No

*Do you exercise regularly? (what / long / often) Yes No

Has there been a recent change in exercise ability? Yes No

Other exercise tolerance issues Yes No

*Pulmonary / Lungs None Pulmonary note

*Asthma Yes No

*Bronchitis or Emphysema Yes No

*COPD Yes No

*CPAP machine Yes No

*Do you currently smoke? Yes No

Do you snore? Yes No

Lung blood clots (date) Yes No

Lung mass/surgery Yes No

*Oxygen dependent Yes No

Pneumonia (date) Yes No

Recent flu or productive cough Yes No

Short of breath at rest – pulmonary Yes No

*Sleep apnea Yes No

Tuberculosis Yes No

Other pulmonary/lung issues Yes No

*Metabolic / Endocrine None Metabolic note

Adrenal or pituitary gland problems Yes No Gestational diabetes Yes No Gout Yes No *Insulin dependent diabetic Yes No

*Non-insulin dependent diabetic Yes No

Is patient last Hgb A1C >7.5? Yes No *Is patient’s average fasting BG > 100? Yes No

Prednisone/steroid use within last 6 months Yes No

Thyroid disease Yes No

Other metabolic issues Yes No

Does the patient have an insulin pump? Yes No

*Gastrointestinal None GI note

Frequent diarrhea Yes No

GI bleeding Yes No

*Heartburn/acid reflux (GERD) Yes No

Hiatal hernia Yes No

Irritable/inflammatory bowel disease Yes No

Pancreatitis Yes No

Rectal bleeding; black/bloody stool Yes No

Stomach surgery Yes No

Ulcers Yes No

Other gastrointestinal issues Yes No

Gentourinary None GU note

Incontinence – urine Yes No

Other genitourinary issues Yes No

*Renal / Kidney None Renal note

*Dialysis Yes No

*Kidney disease or infection Yes No

Kidney failure Yes No

Kidney transplant Yes No

*Other renal/kidney issues Yes No

Hepatic / Liver

None Hepatic note

Cirrhosis Yes No

Current /former alcoholic Yes No

Hepatic Yes No

Liver disease Yes No

Other hepatic/liver issues Yes No

Hematology / Blood None Hematology note

Anemia Yes No

Easy bruising or bleeding Yes No

Hemophilia Yes No

Sickle cell anemia Yes No

Thalassemia Yes No

Unusual or prolonged bleeding Yes No

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Other hematology/blood issues Yes No

Muscle / Skeletal None Muscle/Skeletal note

Chronic back pain Yes No

Joint replacement Yes No

Joint stiffness Yes No

Lupus Yes No

Muscular dystrophy Yes No

Myasthenia gravis Yes No

Rheumatoid arthritis Yes No

Other muscle/skeletal issues Yes No

Neurological None Neurological note

Brain injury Yes No

Brain surgery Yes No

Brain tumors Yes No

Dementia/Alzheimer’s disease Yes No

Fainting/loss of consciousness (date) Yes No

Headaches/migraines Yes No

Multiple sclerosis Yes No

Parkinson’s disease Yes No

Prolonged nerve paralysis or numbness Yes No

Spina Bifida Yes No

Spinal cord injury/tumor Yes No

Stroke (date) Yes No

Other neurological issues Yes No

Integumentary None Integumentary Note

Rash/itching Yes No

Severe burn in the last 2 years Yes No

Skin problem Yes No

Other Integumentary issues

*Infectious Disease None

Infectious Disease Note

HIV Yes No

*Resistant bacterial infection (MRSA/MSSA/VRE) Yes No

Acinetobacter baumannii Yes No

Clostridium difficile (C Difficile) Yes No

Cytomegalovirus (CMV) Yes No

Extended spectrum beta-lactamase Yes No

Group B strep Yes No

Other infectious disease issues Yes No



Cancer None Cancer note

Cancer type Cancer treatment

Females only N/A Female Note

Currently breast feeding Yes No Last menstrual period (date) Yes No Currently/possible pregnant Yes No Other female issues Yes No Currently / Possibly pregnant Yes No Behavioral Health None Behavioral Health Note

Anxiety Yes No

Depression Yes No

Schizophrenia Yes No

Other behavioral health issues Yes No

Have you had any previous operations? If numerous please list last 6 only

None

Surgery date Description Previous Surgery Comment

1.

2.

3.

4.

5.

6.

Visual Aids Vision Impaired Hearing Aids Hearing Impaired

Yes Blind left eye Yes Profoundly deaf left ear No Blind right eye No Profoundly deaf right ear Eye glasses Impaired left eye Right Hard of hearing left ear Contacts Impaired right eye Left Hard of hearing right ear Other Bilateral

Other Implanted devices Yes No

*Additional Medical History

Communicable Diseases

Exposure to Chicken Pox in last 3 weeks Yes No

TB screening Cough and night sweats lasting longer than 2 weeks No prenatal care Positive PPD without CXR and/or symptomatic Pulmonary symptoms (productive cough, fever > 2 weeks) None of the above; (next section not necessary



SCREENING QUESTIONS

Do you have any special diet request based on religious / cultural practices or and preferences that need to be part of your care?

Yes No

Describe food preferences or special diet:

Have you been eating less than all of your meals during the last week? (other than a doctors order not to eat)

Yes No

Do you have difficulty eating or do you cough or choke while swallowing food/liquids

Yes (discuss with physician) No

Do you have a new problem with understanding, communicating, or talking?

Yes (relates to current admission) No Yes ( discuss with physician)

Have you had recent decrease in your ability to do your self care activities?

Yes (relates to current admission) No Yes (discuss with physician)

Are there any religious/cultural practices that will affect your care?

Describe:

Yes No

Would you like a spiritual advisor (Priest, Rabbi, etc) to visit you? Yes No Request to see personal advisor Request a pastoral care consult

Do you have objections in receiving blood products?

Describe objection to receiving blood:

Yes No

Do you use or are you interested in receiving integrative therapies during this hospitalization? Describe:

Yes No (Reiki, acupuncture, etc.- may not be available in all facilities)

Do you currently have an intravenous device (PICC line, mid line port) in your arm or chest; or any other catheter in your chest or neck?

Yes No

Do you currently have Home Health Services visiting you? Yes No Name of Agency:

Do you live anywhere other than a private residence? Yes No Name of Facility:

# SOCIAL HABITS Do you have more than 10 alcoholic drinks per week? If so, what type, frequency, amount, and last use?

Yes No

If you are pregnant, have you consumed alcohol during your pregnancy? Yes No N/A

Have you smoked within the last 12 months? If so, what type, cigarette use (packs per day), other tobacco frequency, and last use?

Yes No

Exposure to tobacco smoke: Exposed at work Live with someone who smokes Patient smokes Other

Do you use illicit (street) drugs? If so, what type, frequency, amount, and last use?

Yes No

If Patient is pregnant, and above screening questions are checked; complete the following: Bloody sputum Yes No History of exposure to TB Yes No History of positive TB skin test Yes No History of positive chest x-ray for TB Yes No Treated for TB Yes No PPD result non screened

or not available negative positive

Chest X-Ray results neg pos none

general information patient database

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