EVALUATION OF MEDICAL CONDITION AND NURSING CARE REQUIREMENTS OF PROSPECTIVE MALADE ALL

Transcription

EVALUATION OF MEDICAL CONDITION AND NURSING CARE REQUIREMENTS OF PROSPECTIVE MALADE ALL
2015 LOURDES PILGRIMAGE
29 APRIL – 6 MAY, 2015
EVALUATION OF MEDICAL CONDITION AND NURSING CARE
REQUIREMENTS OF PROSPECTIVE MALADE
IT IS NECESSARY TO ANSWER ALL QUESTIONS.
INSTRUCTIONS
Malade applicant should complete Page 1 and pages 2-5 MUST be completed by treating physician
or a member of the physician's staff (NOT by malade). It is not necessary to send additional
medical information unless your treating physician deems it necessary for clarification of your medical
history. Please print legibly (or type) all answers. The original completed and signed Medical Evaluation
form must be submitted as part of the completed 2015 Malade Application packet (per Application Check
List) by Friday, November 14, 2014.
_____________________________________________________________________________________
Full Name of Prospective Malade
Date of Birth
_____________________________________________________________________________________
Address
Preferred Phone
_____________________________________________________________________________________
City
State
Zip
_____________________________________________________________________________________
Sponsor’s Name
Sponsor Phone #
_____________________________________________________________________________________
Sponsor City
Sponsor Region
If you have any questions with regard to the Medical Evaluation Form
please contact the Pilgrimage Chief Nurse, Joan Cincotta, RN
315.446.5543 (home), 315.420.9486 (cell) or [email protected] (email)
Order of Malta, Federal Association, USA
1730 M Street, NW Suite 403
Washington, DC 20036-4517
Phone: 202.331.2494 | www.orderofmalta-federal.org
Page 1 of 5
Name of Patient: ___________________________ Page 2 of 5
HISTORY OF PRESENT ILLNESS
General Description of Disability
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Associated Medical or Surgical Conditions
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Medications
Please list all your medications and include condition, dosage & schedule. Please attach a listing in
this format if additional space is necessary. Important note: medical marijuana is prohibited on any
international flight and is illegal in France .
Medication
Condition
Dosage
Schedule
Name of Patient: ___________________________
Page 3 of 5
**ALLERGIES (medication and food) Also describe reaction(s)** This information is required
_________________________________________________________________________________
_________________________________________________________________________________
DETAILED REVIEW OF SYSTEMS
1.
CARDIOVASCULAR: Problem: No ____ Yes_____ If yes, specify: Chest Pain _____ Shortness of
Breath______ Palpitations_____ Swelling of lower extremities _____ Blood Pressure _____ Stroke _____
Comments: __________________________________________________________________________________
2.
RESPIRATORY: Problem: No _____ Yes _____ If yes, specifiy: Cough _____ Shortness of Breath _____
Abnormal sputum _____ Other: _________________________________________________________________
3.
HEARING: Problem: No _____ Yes _____ If yes, describe: __________________________________________
4.
VISION: Problem: No _____ Yes _____ If yes, describe: ____________________________________________
5.
GASTRO-INTESTINAL: Problem: No _____ Yes _____ If yes, specify: _________________________________
Pain _____ Nausea _____ Vomiting _____ Ileostomy _____ Colostomy _____ Other: ______________________
6.
BOWEL: Problem: No _____ Yes _____ If yes, specify: _____________________________________________
Constipation _____ Diarrhea _____ Incontinence: frequent _____ occasional _____
Level of care: Self _____ Physical Assistance _____ Specify: _________________________________________
Comments: _________________________________________________________________________________
7.
URINARY: Problem: No _____ Yes _____ If yes, specify: Frequency _____ Pain _____
Incontinence: frequent _____ occasional _____ bedwetting _____
Assistive devices: Catheter _____ External _____ Indwelling _____
Other: _____________________________________________________________________________________
Level of care: Self _____ Physical Assistance _____ Specify: _________________________________________
Comments: _________________________________________________________________________________
8.
NUTRITION: Problem: No _____ Yes _____ If yes, describe: ________________________________________
Level of nutritional care needed: _________________________________________________________________
Special Diet: No _____ Yes _____ Specify: _______________________________________________________
Needs to be fed: No _____ Yes _____
Comments: __________________________________________________________________________________
Name of Patient: ___________________________
9.
Page 4 of 5
NEUROMUSCULAR Problem: Check all application items: Ambulatory _____ Ambulatory with limitation _____
Non-ambulatory _____ Amputation: No _____ Yes _____ if yes, describe: ______________________________
Paralysis: No _____ Yes _____ If yes, describe: ___________________________________________________
Seizures: No _____ Yes _____ If yes, type: _________________________ Frequency: __________________
Significant limitation of motion: No _____ Yes _____ If yes, describe: __________________________________
Supportive devices: Cast _____ Bandage _____ Brace _____ Describe: _________________________________
Comments: _________________________________________________________________________________
10. HYGEINE / GROOMING: Level of care needed: ____________________________________________________
Bathing:
Self _____ Assistance: Total _____ Partial _____
Dressing:
Self _____ Assistance: Total _____ Partial _____
Hair:
Self _____ Assistance: Total _____ Partial _____
11. PSYCHIATRIC: Problem: No _____ Yes _____ If yes, specify: ________________________________________
___________________________________________________________________________________________
Anxiety: ______________ Depression:______________ Mood Swings:______________ Irritability: __________
12. SKIN: Problem: No _____ Yes _____ Pressure sores _____
Describe: ___________________________________________________________________________________
PHYSICAL EXAMINATION
Height: _______________
Weight: _______________
Blood Pressure: ______________
Ears:
Normal
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_____________________________________________________________
Eyes:
Normal

_____________________________________________________________
Nose:
Normal

_____________________________________________________________
Throat:
Normal

_____________________________________________________________
Lungs:
Normal

_____________________________________________________________
Heart:
Normal

_____________________________________________________________
Abdomen:
Normal

_____________________________________________________________
Genitalia:
Normal

_____________________________________________________________
Rectal:
Normal
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_____________________________________________________________
Skin:
Normal

_____________________________________________________________
Extremities:
Normal

_____________________________________________________________
Name of Patient: ___________________________
Page 5 of 5
Comments: _____________________________________________________________________________________
_______________________________________________________________________________________________
Diagnosis: _____________________________________________________________________________________
_______________________________________________________________________________________________
Specific Nursing Care Requirement:
NONE
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_____________________________________________________________________________________
_______________________________________________________________________________________________
Is this patient medically stable to travel to Lourdes, France?
Yes _____ No _____
Will this patient require the use of a portable oxygen canister?
Yes _____ No _____
Will this patient require the use of any electrical device?
Yes _____ No _____
GENERAL INFORMATION
Does this individual have difficulty walking long distance?
Yes _____ No _____
Can this individual sit in a standard coach airline seat for a 9-hour flight?
Yes _____ No _____
Does this individual speak English?
Yes _____ No _____
IT IS NECESSARY TO ANSWER ALL THE QUESTIONS ABOVE.
_____________________________________________________________________________________
Physician’s Signature
Print Physician’s Name
Dated
_____________________________________________________________________________________
Physician’s Address
_____________________________________________________________________________________
Physician’s Phone #
Physician’s Fax
Mobile/Pager
_____________________________________________________________________________________
Physician’s Email
Order of Malta, Federal Association, USA
1730 M Street, NW Suite 403 | Washington, DC 20036-4517
Phone: 202.331.2494 | www.orderofmalta-federal.org