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)
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
MATERIAL SAFETY DATA SHEET COOPEX® Insecticidal Dusting Powder Industrial Strength Date of Issue: October 10, 2002 1. IDENTIFICATION OF THE SUBSTANCE / MIXTURE AND SUPPLIER Product name: COOPEX® Insecticidal Dusting Powder Industrial Strength Other names: Product code: SAP Product code: Recommended A ready-to-use insecticidal dusting powder use: Supplier: