Medical Clearance
We require that all clients admitting to The Highlands receive a physical exam no more than seven
days prior to their admission. The physical exam will include:
Client’s Name / Date of Birth: ___________________________________________________________
•
A complete assessment of the client’s general health, including the following, is required:
o CBC with Differential and Platelets
o Comprehensive Metabolic Profile
o EKG
o TB test (All clients shall show proof of having a tuberculosis test within the past year or shall
have such a test within 7 days prior to admission to the facility; TB test can be obtained through
a local health department or physician’s office)
o 10 panel urine drug screen
Requirements for Admission:






Declared medically stable by a physician to receive treatment at a partial hospitalization or intensive
outpatient treatment facility.
Negative Tuberculosis test result.
Ability to manage pre-existing medical conditions.
Clients admitting to The Highlands with personal glucometers will require a MD statement upon
admission stating that the client is competent in performing blood glucose testing/monitoring for the
particular monitor or insulin pump.
Be free from any infectious or contagious diseases that would preclude care of the person by the
licensee.
Must be ambulatory.
Deaf / Hard of Hearing:
If any client is deaf or hard of hearing, arrangements will be made for interpretive services.
Urine Drug Screen / Alcohol Screen
Please note that a urine drug screen and an alcohol screen will also be conducted on the day of admission.
Executive / Clinical Director:_______________________________________________________________
(Signature indicating Admission Approval & Date)
Medical Director / Registered Nurse: ________________________________________________________
(Signature indicating Admission Approval & Date)
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Physician's Report for Medical Clearance
To be completed by a Physician or Nurse Practitioner: Note: The person named below is requesting
admission to the The Highlands, in Birmingham, Alabama. We must have medical clearance prior to
her admission, as we are not a medical facility. Please be sure to address all questions:
Name of Patient (print) __________________________________________________________
Sex __________
Height __________
Weight __________ DOB _____/_____/_____
Primary Diagnoses ________________________________________________________________________
Secondary Diagnoses ______________________________________________________________________
Other Physical or Mental Conditions ___________________________________________________________
History and Physical Summary:
Blood Pressure (sitting) _____________________
Blood Pressure (standing) _____________________
Blood Pressure (lying) _____________________
Pulse _____________________________________Respirations ___________________________________
Temperature __________________________
TB Test Date and Results ___________________________________________________________________
EKG Test Date and Results__________________________________________________________________
Last known tetanus shot____________________________________________________________________
Exercise Clearance: (check one)
⃞ Based on the patient’s h&p, s/he is medically cleared to participate in physical activity.
⃞ Based on the patient’s h&p, s/he is not medically cleared to participate in physical activity
(Please note: this item is not an exclusion for acceptance into the treatment program.)
Reason not cleared for physical activity: __________________________________________________
List any athletic injuries/history of stress fractures: ________________________________________________
________________________________________________________________________________________
Hospitalizations:
List any medical hospitalizations/surgeries in patient’s life__________________________________________
________________________________________________________________________________________
List any psychiatric hospitalizations in patient’s life (including previous eating disorder treatment)___________
________________________________________________________________________________________
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Allergies:
Allergies (medications, foods, environmental, animals) with an explanation of the side effects noted from said
allergy__________________________________________________________________________________
________________________________________________________________________________________
Diet:
Dietary Restrictions (e.g. vegetarian) (Please note: physician must document dietary restrictions for a
specialized diet to be followed at The Highlands)________________________________________________
Is there a medical reason for the above noted dietary restrictions (e.g. high cholesterol, diabetes)? If so,
please note medical reason _________________________________________________________________
Flu season is November thru April. It is recommended that all patients who admit to The Highlands have a flu
vaccination prior to their admission. Please note this patient’s last flu shot._____________________________
History of Seizures ________________________________________________________________________
General Physical Health Status ______________________________________________________________
Prescription and OTC Medications:
MEDICATION
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DOSE/FREQUENCY
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Medical History:
The following diagnoses and symptoms are of particular importance in the management of eating disorders.
Please indicate conditions that apply.
• Diabetes
□ yes
□ no
•
Inflammatory Bowel Disease
□ yes
□ no
•
Crohns disease
□ yes
□ no
•
Cystic Fibrosis
□ yes
□ no
•
Current Contagious/Infectious Disease
□ yes
□ no
•
Liver disease
□ yes
□ no
•
Kidney disease
□ yes
□ no
•
Gallbladder
□ yes
□ no
•
Sleep disorders
□ yes
□ no
•
Hair loss
□ yes
□ no
•
Heartburn/ indigestion
□ yes
□ no
•
Bloating
□ yes
□ no
•
Hematemesis
□ yes
□ no
•
Fainting/ dizziness
□ yes
□ no
•
Palpitations
□ yes
□ no
•
Complications with pregnancy
□ yes
□ no
•
Infertility problems
□ yes
□ no
•
Illicit drug use
□ yes
□ no
•
Osteoporosis/Osteopenia
□ yes
□ no
•
Amenorrhea
□ yes
(Date of Last Menstrual Cycle: __________)
□ no
Mental Health History:
The following diagnoses and symptoms are of particular importance in the management of eating disorders.
Please indicate conditions that apply.
• Depression
□ yes
□ no
•
Anxiety
□ yes
□ no
•
Suicidal ideations
□ yes
□ no
•
Signs/Symptoms of Physical Abuse
□ yes
□ no
•
Homicidal ideations
□ yes
□ no
•
Self Injurious Behaviors
□ yes
□ no
•
Psychosis
□ yes
□ no
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SUBSTANCE
USE DAILY
USE WEEKLY
Tobacco
Alcohol
Coffee, regular
Coffee, decaf
Tea, regular
Tea, decaf
Soft drinks, regular
Soft drink, diet
Artificial sweeteners
Review of Systems
Normal
If Abnormal, describe below:
Skin (lanugo, calluses, etc)
Head
Eyes
Ears
Nose
Mouth/Teeth & Throat
Respiratory
Cardiovascular
Gastrointestinal
Urinary
Musculoskeletal
Endocrine
Hematologic
Neurological
Motor Skills
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Other Information:
Please indicate synopsis of any lab abnormalities (Refer to Medical Clearance Requirements):
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Additional physician comments regarding patient’s clinical status:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Physician's name:
_______________________________________________________________________________________
Physician’s address, city, state, zip:
________________________________________________________________________________________
Physician’s phone:
( )____________________________________________________________________________________
Physician’s FAX:
(
)____________________________________________________________________________________
Physician’s email:
________________________________________________________________________________________
Are you the primary care physician for this patient?
Yes □
No □
If yes, how long have you been the PCP for this patient? _________________________
I hereby certify that the above named patient is medically stable and has completed all requirements
for admission to The Highlands.
Physician's Signature ______________________________ Date ______________________
(please attach business card)
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Please submit this medical clearance form, copies of related lab work, and
TB/EKG results to…
Castlewood at The Highlands
FAX: 636-229-4497
Questions? Call: 888-822-8938
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