Collierville alzheimer’s day care center

Page Robbins Adult Day Care Center
Physician’s Form
(Note to Physician: The client and their caregiver below are completing an application for admission to Page
Robbins Adult Day Care Center. We provide day services to adults with dementia and/or who are frail. Please
complete this 3 page form and mail/fax it to our center or give to the primary caregiver. Thank you.)
General Information

______________________________________________ Street Address ______________________________________________ City and State ______________________________________________ Responsible Party/ Legal Guardian __________________________ Phone_______________ Height ______ Drug/Allergies _____________________________ Latex Allergy?______ (Please note that a chest XRay OR a Skin Test must have been completed within the last 6 months.)
Chest X-Ray: Yes_____No_____Date:________Results:_________________
PPD Skin Test: Yes_____No_____Date:________Results:_________________
Identification and Background Information

Last Medical Assessment Date ________________by______________________________
Bowel and Bladder:
Client has complete control of bowel and bladder
If No, Please Explain: _________________________________________________________ Client has one of the following: 1. External Catheter ______ 2. In-dwelling Catheter ______ 3. Pads, Briefs ______ 4. Ostomy (Please Specify) ______ 5. None ______ 6. Other ______ Client has been tested for a Urinary Tract Infection in the last 60 days Yes______No______ If Yes, Medication Prescribed: __________________________________________________ Page Robbins Adult Day Care Center Medical Form
Disease Diagnosis (Please check if yes)

Heart/Circulation
Arteriosclerotic Heart Disease
Other Cardiovascular Disease:________________
Neurological
Alzheimer’s disease
Other (Please specify) __________________________________________________________________
Pulmonary
Emphysema
Other: (Please specify) _________________________________________________________________
Psychiatric/Mood
Anxiety Disorder
Other: (Please specify): ________________________________________________________________
Vision

Other:
Anemia
7. Past Surgical History: ____________________________________________________________________ 8. Other Health Conditions: _________________________________________________________________ Page Robbins Adult Day Care Center Medical Form
Existing Conditions:
Constipation

Ambulation:
Independent
Please specify: ___________________________
Current Medications
(Please include: Name, Dosage, Frequency and Reason for Medication)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Non-Prescription Drugs (Given at the center PRN according to label if symptoms occur)
Tylenol 500 mg, 1 tab every 3-4hours

I certify that _____________________________________is free from Communicable Disease
Client’s Name)
and able to participate in an Adult Day Care Program.
_______________________________________ ___________________________
Physician (Please sign and Print Name) Date
_______________________________________
Physician Address Physician Phone Number Page Robbins Adult Day Care Center Medical Form

Source: http://pagerobbins.org/wp-content/uploads/Current-Physicians-Statement-Form-april-2011.pdf