Patient Name: Date of Admission or Procedure:

Abington Memorial Hospital

PATIENT INSTRUCTIONS: Please complete all sections on each page or have someone complete it for you. Answer by “ ✔ ” when appropriate. Please bring this completed form with you to your Preadmission Center appointment. PERSONAL INFORMATION Patient Name: Date of Admission or Procedure: Admitting Physician or Surgeon: Person providing information: Relationship: Language spoken: Is an interpreter needed? Name and phone # of interpreter: Do you have a living will? YES NO YES UNKNOWN NO Phone # English YES Other NO Date:

Do you have a durable power of attorney for healthcare? If “yes”: Name

(If “yes” to above question, please bring a copy to the hospital on admission.) Are you an Organ Donor? Primary Physician: REASON FOR ADMISSION (please describe): YES NO UNKNOWN Phone #


List Allergies and Reactions:

Visit us at Email the Preadmission Center at

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PATIENT HEALTH ASSESSMENT Patient Name: Date of Admission or Procedure: Abington Memorial Hospital Current weight *Weight 1 Email the Preadmission Center at patnurse@amh. home remedies): Name of medication Dose and Frequency None Herbal preparations: Have you had any changes in medication in the past 30 days? YES NO Visit us at www. over the 2 of 8 . ago Alcohol Use: Denies beer Drinks socially Tobacco use: Denies cigarettes Current cigars Current liquor Actual Height Past wine per day Past pipe Estimated Other: per week chew How many cigarettes do you smoke a day? Do you have a cigarette within one hour of awakening? Illicit drug use: Never Past Now Not applicable Peritoneal Dialysis Dialysis YES NO Are you undergoing any treatments: Chemotherapy Other Immunizations: Tetanus/Yr Other/Yr Radiation Flu vaccine/Yr Pneumonia vaccine/ Yr Medications taken regularly (Prescription. 3 of 8 .org Email the Preadmission Center at patnurse@amh.PATIENT HEALTH ASSESSMENT Patient Name: Date of Admission or Procedure: RESPIRATORY/LUNGS: Asthma Cancer Chronic bronchitis Chronic cough/cough with mucus Emphysema VASCULAR/HEART: Abnormal EKG Blood clots Cancer Chest pain Chest Pressure Circulation problems Fainting episodes NEUROLOGICAL/BRAIN/ SPINAL CORD: Alzheimers Back pain Cancer Difficulty learning Difficulty speaking Difficulty with balance Dizziness No problems Loud snoring Pneumonia Positive TB test Recent cold or flu Shortness of breath No problems Heart attack Heart blockage Heart murmur High/Low blood pressure Internal defibrillator Irregular heart beat Pacemaker Abington Memorial Hospital Sleep apnea TB Tracheotomy Wheezing Palpitations Phlebitis Swelling of feet/ankles/legs Valve disorder Varicose veins No problems Fainting Frequent headache Memory problems Mini stroke Neck pain Numbness Paralysis of arm/leg L R Seizures Severe headaches Speech slurred Stroke Tingling of arm/leg Weakness L R Visit us at www.

Internal Fixators No problems Abington Memorial Hospital No problems Irritable bowel Jaundice Pancreatitis Rectal bleeding Nausea/vomiting Ulcer Sciatica TMJ pain or jaw disorder BLOOD: Anemia Blood transfusion Cancer Easy bruising Frequent nosebleeds Immunosuppressed No problems PSYCHIATRIC: Anger Anxiety Dementia Depression No problems Eating disorder Hallucinations Manic depression Mood swings Schizophrenia Suicide attempt Visit us at Email the Preadmission Center at patnurse@amh. Rods.PATIENT HEALTH ASSESSMENT Patient Name: Date of Admission or Procedure: GASTROINTESTINAL/BOWEL/DIGESTIVE: Bowel obstruction Cancer Chronic diarrhea Cirrhosis of liver Colitis Colostomy Constipation MUSKULOSKELETAL: Arthritis Artificial joint(s) Cancer Fracture Gout ENDOCRINE: Cancer Diabetes Hormone disorder Low blood sugar Thyroid disorder Crohn’s disease Excessive burping Heartburn Hemorrhoids Hepatitis Hiatal hernia Iliostomy No problems Lupus Muscle disease Muscle weakness Osteoporosis 4 of 8 .

PATIENT HEALTH ASSESSMENT Patient Name: Date of Admission or Procedure: SKIN: Bed sore Non-healing sores Rashes URINARY/REPRODUCTIVE: Blood in urine Burning Cancer Difficult urination Frequent urination Infections Kidney stones No problems Shingles Skin Cancer Skin disorder No problems Loss of control Pain Prostate Problems (males) Self Catheterization Sexually transmitted diseases Urinary catheter (presently) Ureterostomy Abington Memorial Hospital Ulcerations Females: Last menstrual period: Pregnant: Yes No Unsure Weeks pregnant: Due date: Breast feeding EYES/EARS/NOSE/THROAT: Blind Cancer Cataracts Contact lenses Corneal Implants OPERATION PROCEDURES: List all surgeries and approximate dates: No problems Deaf Deviated septum Glasses Glaucoma Hearing aids None Hearing impairment Ringing in ears Sinus problems TTY needed Visit us at 5 of 8 .org Email the Preadmission Center at patnurse@amh.

or spiritual beliefs that we need to know in order to provide care for you? Yes Are there any spiritual needs that we need to address while you are in the hospital? Visit us at No No Yes 6 of 8 .org Email the Preadmission Center at patnurse@amh. problems with airway/breathing Difficulty waking up from anesthesia You required ventilator after surgery Blood relative required ventilator after surgery Severe nausea after surgery NUTRITION: Special Diet: Cardiac Chopped/soft Cultural-specific diet No problems No restrictions Diabetic Feeding tube Fluid restriction No 1-5 lbs (1 point) 6-10 lbs (2 points) 11-15 lbs (3 points) Have you been eating poorly because of a decreased appetite? No (0 points) Yes (1 point) Kosher No problems Abington Memorial Hospital DENTAL HISTORY: Braces Bridges Broken teeth Caps Implants Loose teeth No problems Dentures: Upper: Full Lower: Full Partial Partial Thick It Vegetarian Low salt diet Renal Unsure Yes Have you lost weight recently without trying? If yes. Coping strategies Family issues Medical advocate Pastoral Care Psychiatric crisis Social Work Support group Work issues Are there any cultural. religious.amh.PATIENT HEALTH ASSESSMENT Patient Name: Date of Admission or Procedure: ANESTHESIA: Never had anesthesia You or a blood relative had unexplained fever right after surgery Difficult intubation. how much weight have you lost? >15 lbs (4 points) Unsure (2 points) Total screening score: ADJUSTMENT TO ILLNESS: Request for Support or Counseling: Please check all those that apply.

org Email the Preadmission Center at 7 of 8 .PATIENT HEALTH ASSESSMENT Patient Name: Date of Admission or Procedure: DISCHARGE/DISPOSITION: Living Arrangements – Patient lives in: Apartment House Personal care facility Skilled nursing facility Long term care facility SELF CARE: Abington Memorial Hospital No problems Needs help with: Bathing Cooking Dressing Eating Homemaking Toileting Patient lives with: Alone Adult Child Parent Private aide Name of Person: Sibling Spouse Friend/Other Place patient is planning to go at discharge: Home Unknown Preadmission Residence Person Responsible for transportation home: Name of Person: Phone # Phone # Support available at home: Full-time Part-time Undetermined No help available Has 24-hour companion at home: Family Friend Spouse Yes No Attendant (private aide) Visit us at www.

org Email the Preadmission Center at 8 of 8 .amh.PATIENT HEALTH ASSESSMENT Patient Name: Date of Admission or Procedure: CURRENT HOME CARE SERVICES/EQUIPMENT: Day Care Hospice Name of Agency: Patient Uses: Cane Commode Grab bar MOBILITY/ACTIVITY: Ambulatory / Walks well alone Supervision: Minimal Moderate Maximum Patient is bed bound Independent Hospital bed Oxygen Therapy Tub bench Wheelchair Name of company: Nursing Care Occupational Therapy Abington Memorial Hospital Not applicable Physical Therapy Social Worker Speech Therapy Requires assistance Prosthetic device: Assistive Devices Used: Cane Crutches Hemicane Walker Wheeled walker Wheelchair Communications level/Devices: Normal Impaired Please state anything else you think we should know: Visit us at www.

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