How do you prefer we communicate?
  
Phone/Text   Area Code   Phone Number          
Email:   Email      

   MEDICATIONS - Prescriptions, Vitamins, Over-the-Counter

If you are on any new medications since your last visit please list them below.  
Name Dose   Date Started   Condition Treating   
Name   Dose   Date Started   Condition Treating
Name   Dose   Date Started   Condition Treating  
Name   Dose   Date Started   Condition Treating   
Name   Dose   Date Started   Condition Treating   
Name   Dose   Date Started   Condition Treating   
Name   Dose   Date Started   Condition Treating   
Name   Dose   Date Started   Condition Treating   
Name   Dose   Date Starting   Condition Treating    

Activities of daily living (ADL's) - Please select all those that apply.

Which of the following can you do on your own without help?
Bathe    Dress    Eat    Walk    Use the restroom    Transfer in/out of chairs, etc    None   
   

Does someone help you at home?   Yes   No 
    Spouse   Children   Other:         
If yes, please provide Caregiver Name:
First Name   Last Name   
Aide/Caregiver #:
Area Code   Phone Number   

Instrumental activities of daily living (IADL’s) - Please select those that apply.

Which of the following can you do on your own without help?
Shop for groceries Use the telephone      Housework    Handle finances Drive/Use public transportation    Take Medications Make meals    None   

Which of these assistive devices do you use?
Please select all that apply
Cane Walker    Wheelchair
Crutches    Other    None      

Does your family or friends know what you want in an emergency situation or if you could not speak for yourself?
Please select all that apply
If you have any of the following, it would be helpful to have a copy provided to us for your medical record.
Yes, I have a living will   
Yes, I have a power of attorney   
Yes, I have a POLST   
Yes, I have completed 5 wishes   
No