Form F5 - Medical Form For Adults - Department Of Human Services - Division Of Developmental Disabilities
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STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES - DIVISION OF DEVELOPMENTAL DISABILITIES
Medical Form for Adults
Name: ____________________________ Age: ______ DOB: ________ { } Male { } Female
Health Insurance #: _____________________
SS#: ______________
Exam Date: _________
A.
HISTORY:
1)
Indicate any present and past medical condition (include communicable disease history):
2)
Previous hospitalizations/surgery:
3)
Immunizations:
Adult Diphtheria/Tetanus-Date: _________
(Document date of last booster OR administer if more than 10 years ago.)
Hepatitis B Immunization (if given) Date: [1] _________
[2] _________
[3] _________
B.
LABORATORY TESTS:
1)
Mantoux Test yearly if non-reactor or chest x-ray if indicated. Past or current results must be documented:
Results: ______________________________________________
Date: _____________
Tine test is not acceptable. Positive Mantoux reactor should never be retested.
2)
Hepatitis B Profile: Initial (repeat at physician’s discretion).
Results: ______________________________________________
Date: _____________
(Past or current results must be documented).
3)
Lead Poisoning: Blood Lead Level is required:
a.
For Individuals with known Pica behavior, test annually, or according to guidelines for elevated lead levels
b.
Prior to discharge from development center (within 3 months of discharge).
c.
For all new admissions to Divisional residential services (within 3 months prior to admission or within 10 days
after admission).
Blood Level: ________________________________________
Date: ___________
4)
SMAC, initial (repeat at physician’s discretion):
5)
Complete Blood Count, initial (repeat at physician’s discretion):
6)
Urinalysis, initial (repeat at physician’s discretion):
7)
Serology, initial (repeat at physician’s discretion):
8)
Pap Smear (follow American Cancer Society guidelines):
9)
EKG – initial at age 40 (repeat at physician’s discretion):
C.
OTHER MEDICAL CONDITIONS/NEEDS:
1)
Seizures: { } Yes { } No
Frequency & Type, if known:
2)
Special Dietary Needs: { } Yes { } No
(Attach Prescription):
3)
Allergies, Sensitivities: (foods, drugs, others):
4)
Mental Health Problems (Behavioral/Psychiatric Disorders):
DDD Day Program Manual 11/06
Forms: Form F5
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