Emergency Room/hospital Admittance Form printable pdf download

EMERGENCY ROOM/HOSPITAL ADMITTANCE FORM

Form to be completed by residential staff prior to bringing the individual with

mental retardation to the Emergency Room or admitting the individual to the hospital.

: ______________

Date: ___________ Completed by: ___________________ Relationship to Individual

Name: __________________________________

Nickname/Likes to be called: ________________________

DOB: _______________ Soc Sec #: _____________________

Health Insurance (Type & Numbers)

Address: ___________________________________________

Primary: ________________________

__________________________________________________

Phone #: __________________________________________

Secondary: ______________________

Allergies: __________________________________________

Living Status: Group Home____ Family Living____ Lives Independently _______ Other_________________

Nursing Supports Available at provider agency? (circle) Yes or No; RN and/or LPN Name: ________________

Emergency Contacts

Name (Provider Agency):_________________________

Name (Family): _______________________

Phone Number: ________________________________

Relationship: _________________________

Phone Number (After Hours): _____________________

Phone Number: ________________________

County Contact Person: __________________________

Phone Number: _________________________________

Phone Number (After Hours): ______________________

Primary Care Physician: ____________________________

Reason for ER visit today:

Phone Number: __________________________________

Neurologist: _____________________________________

Phone Number: __________________________________

Current Medical Problems/Diagnoses:

Psychiatrist: _____________________________________

Phone Number: ___________________________________

Level of Mental Retardation (circle one):

Mild Moderate Severe Profound

Consent Status:

CAN give own consent

CANNOT give own consent. Has a Legal Guardian.

Legal Guardian: _____________________________ Phone Number: ___________________

CANNOT give own consent. Does not have a Legal Guardian. Has a Substitute Healthcare Decision

Maker.

Name: ____________________________________ Phone Number: ___________________

Medical Durable POA: _______________________ Phone Number: ___________________

Resuscitation Status:

DNR****

Full Resuscitation

If DNR, List Reason: _______________________ Date DNR Given: ________ By Whom: ________________

Consent for Release of Information to Provider(circle one): Yes No

Date of Last Tetanus: ____________

Date of Last PPD: ____________

Date of Last Flue Shot: ____________

Date of Last Pneumovax: ________________________ Date of Hepatitis B Vaccines: ______________________

Emergency Room/hospital Admittance Form

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