Emergency Room Form

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: ___________________________________________
__________________________________________________
Phone #: __________________________________________
Primary: ________________________
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):_________________________
Phone Number: ________________________________
Phone Number (After Hours): _____________________
Name (Family): _______________________

Relationship: _________________________
Phone Number: ________________________
County Contact Person: __________________________

Phone Number: _________________________________
Phone Number (After Hours): ______________________
Primary Care Physician: ____________________________
Phone Number: __________________________________
Neurologist: _____________________________________
Phone Number: __________________________________
Psychiatrist: _____________________________________
Phone Number: ___________________________________
Reason for ER visit today:
Current Medical Problems/Diagnoses:
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: ______________________
Communication
Administration:
***Please
be advised: per Dept. of Public WelfareMedication
Mental Retardation
Bulletin #00-98-08Ambulation:
(Procedure for Substitute Health Care
Able to Communicate
Independent/Self
Medicates
Independent
Steady Unsteady
Decision
Making) DNR Status MUST be discussed
with the Provider
Agency listed above.
Communication Difficulties/Uses verbalizations
Communication Difficulties/Uses gestures
Not able to communicate needs
Unable to use call bell
Medication Administered by Staff
Dining/Eating
Independent
Needs Assistance
Vision:
Hearing:
Totally Dependent
Normal
Normal
Fed Through a Tube
Low Vision
Hard of Hearing (Left/Right) Other ________
Blind
Deaf (Left/Right)
Wears glasses
Hearing Aid (Left/Right)
Diet Texture
Regular
Wears contact lenses
Chopped
Supportive Devices: Toileting Ability:
Ground
Padded side rails
Continent
Puree
Splints
Needs Assistance
Thickened Liquid
Braces
Incontinent
Helmut
Catheterized
Diet Type________________
Other ________
Other________
Last Meal Eaten ___________
Needs Assistance
Walker
Wheelchair
1 Person 2 Person
Cane
Crutches
Non-Ambulatory
Personal Hygiene
Independent
Special Needs ____________
Oral Hygiene
Independent
Special Needs ____________
Dentures (Upper/Lower/Partial)
Head of Bed Elevated (Yes/No)
SPECIAL NEEDS
Usual Response to Medical Exams: Cooperates Partially Cooperates Resistant/Becomes Agitated Fearful/Anxious
Any sedation required for clinical visits____________________________________________________________
Special positioning required for examination _______________________________________________________
Staff required for assistance with exams ___________________________________________________________
Requires limited waiting periods for exams
Prefers early day appointments
Prefers end of day appointments
Special communication device/method ____________________________________________________________
Pain Response: Normal Unique ______________________________________________________________
Medical History: Known Unknown

For information, contact: ____________________________ Relationship ________________________
Phone _____________________ Address___________________________________________________
SURGICAL
List all previous surgeries and dates (most recent first):
___________________________________________
___________________________________________
___________________________________________
Any previous problems with anesthesia:

No Yes ________________________________
List any serious trauma or broken bones:
___________________________________________
___________________________________________
MEDICAL
List all serious medical illnesses (e.g. pneumonia, heart
attack) and ongoing medical problems (e.g. diabetes,
high blood pressure, epilepsy) __________________
___________________________________________
___________________________________________
PSYCHIATRIC
List all major behavioral and psychiatric diagnoses
(e.g. depression, schizophrenia, self-injurious behavior)
____________________________________________
WOMENS HEALTH
Currently Pregnant: Yes No
Past History of Childbirth Yes No
Age menstruation started_________________
Age menstruation stopped ________________
Still menstruating
Date of Last PAP_________________
History of Abnormal PAP?
Yes No ____________________
Date of Last Mammogram _________________
MENS HEALTH
Date of Last Prostate Exam__________________
Date of PSA_____________
Normal Abnormal N/A

Emergency Room Form

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EMERGENCY ROOM/HOSPITAL ADMITTANCE FORM

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

Date: _ Completed by: _ Relationship to Individual: ______

Health Insurance (Type & Numbers)

Name (Family): _______________________

County Contact Person: __________________________

Reason for ER visit today:

Current Medical Problems/Diagnoses:

Level of Mental Retardation (circle one):

Medication Administered by Staff

Head of Bed Elevated (Yes/No)

Medical History: Known Unknown

Any previous problems with anesthesia:

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