HIPAA-Compliant New Client Intake & Medical Travel Assessment

HIPAA-Compliant New Client Intake & Medical Travel Assessment

Complete your details, travel plan, and clinical needs to support RN review for medical travel companion services.
Patient Information
Patient full name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex / gender
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Person Arranging Services and Legal Authority
Full Name

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Legal Decision-Maker or Authorized Representative?
Documentation or Authority Details
Origin, Destination, and Travel Reason
Origin Location

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Destination Location

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reason for Travel
Trip Type
Desired Date and Itinerary
Desired travel date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Requested departure window
Requested arrival window
Itinerary complexity
- Current Medical Conditions and Recent Hospitalization
- Current diagnoses / medical conditions
- Recent hospitalization, emergency visit, or surgery?
- Date of most recent hospital, emergency, or surgery event
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Reason for recent admission or event
- Current condition stability
- Nursing and Care Needs
- Walking / ambulation assistance needed?
- Which mobility support does the patient need?
  
  Other
- Transfer assistance needed?
- Which transfer support is needed?
  
  Other
- Which personal care activities need assistance?
  
  Other
- Please describe communication, cognition, or decision-making support needed
- Supervision level required during travel
- Mobility and Medical Equipment
- Current mobility status
  
  Other
- Durable medical equipment needed for travel
  
  Other
- Wheelchair type and size
- Transport requirements for mobility equipment
  
  Other
- How dependent is the client on this equipment
- Who supplies the equipment
  
  Other
- Additional equipment details and special instructions
- Equipment-specific concerns
  
  Other
- Oxygen and Respiratory Details
- Does the patient use supplemental oxygen during travel?
- Oxygen flow rate per minute (if known)
- Oxygen delivery method
- Respiratory diagnoses or concerns
  
  Other
- CPAP/BiPAP settings, if applicable
- Suction needs or other respiratory support concerns
- Medications and Allergies
- Which medication types are you currently taking?
- Please list your current medications and what they are for
- Do any of your medications require special administration or scheduling during travel?
- Please describe any medication timing, storage, or travel handling instructions
- Please list any allergies, intolerances, or adverse reactions to medications
- Clinical Considerations
- History of seizures or seizure-like episodes?
- If yes, please describe seizure type, severity, frequency, last episode, precautions, and any recent changes.
- Recent falls?
- If yes, please describe number of falls, date(s), injuries, circumstances, severity, precautions, and any recent changes.
- Recent fainting or passing out episodes?
- If yes, please describe timing, triggers, duration, severity, evaluation received, precautions, and any recent changes.
- Recent low blood sugar episodes?
- If yes, please describe when episodes occur, symptoms, severity, frequency, treatment used, precautions, and any recent changes.
- Delirium, confusion, or acute mental status changes?
- If yes, please describe onset, duration, severity, triggers, safety concerns, precautions, and any recent changes.
- History of dementia or cognitive decline?
- If yes, please describe diagnosis, current severity, supervision needs, safety concerns, and any recent changes.
- Trouble swallowing or risk of aspiration?
- If yes, please describe symptoms, severity, diet or texture precautions, choking episodes, and any recent changes.
- Recent infection?
- If yes, please describe type of infection, onset, treatment, current status, precautions, and any recent changes.
- Recent surgery or procedure?
- If yes, please describe type, date, recovery status, complications, restrictions, and any recent changes.
- History of bleeding problems or easy bruising?
- If yes, please describe type of bleeding issue, severity, when it occurs, precautions, and any recent changes.
- History of blood clots?
- If yes, please describe location, date, treatment, current status, precautions, and any recent changes.
- Current symptoms or clinical concerns
- Communication and Cognition
- Communication abilities
  
  Other
- Hearing and vision limitations
  
  Other
- Primary language
- Cognition or mental status concerns
- Can the patient understand and participate in care decisions?
- Healthcare Providers and Facilities
- Primary Care Provider Name
  
  First NameMiddle NameLast Name
- Primary Care Provider Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Specialist or Other Provider Name
  
  First NameMiddle NameLast Name
- Specialist or Other Provider Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Facility or Organization Name
- Authorization or Coordination Notes
- Destination and Handoff Arrangements
- Destination care setting
- Expected receiving party
- Handoff instructions
- Accessibility or arrival concerns
  
  Other
- Is a facility handoff or bedside transfer required?
- Emergency Contacts
- Emergency Contacts
- Additional instructions for contacting this person
- Preferred contact method for urgent updates
- Best time to reach primary emergency contact
- Family Goals and Concerns
- Primary goals for the trip
  
  Other
- Main concerns or worries
- Priorities, expectations, or restrictions for planning
- Acknowledgment, Accuracy, and Consent
- Electronic Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Internal RN Review
- Clinical Information Completeness
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Incomplete, 10 is Complete
- Itinerary and Document Review
  
  Other
- Concerns Identified
  
  Other
- Additional Information Requested
- Case Status
- RN Notes
- Follow-Up Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
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HIPAA-Compliant New Client Intake & Medical Travel Assessment

Patient Information

Person Arranging Services and Legal Authority

Origin, Destination, and Travel Reason

Desired Date and Itinerary

Current Medical Conditions and Recent Hospitalization

Nursing and Care Needs

Mobility and Medical Equipment

Oxygen and Respiratory Details

Medications and Allergies

Clinical Considerations

Communication and Cognition

Healthcare Providers and Facilities

Destination and Handoff Arrangements

Emergency Contacts

Family Goals and Concerns

Acknowledgment, Accuracy, and Consent

Internal RN Review