Medical Form
Page 1
PHYSICAL EXAMINATION
Must be completed fully by a Licensed Physician for persons under 18 and/or
persons of any age requiring medication assistance
Patient Name_______________________________________ Exam date:____________
Address:________________________________________________________________
City:____________________________________ State:___________ Zip:___________
Patient Phone # ( )_______________________________________
Date of Birth ________/________/_______ Age:____________
Height____ Weight_____ Blood Pressure_____
Vision (Please Check One)
Eye condition (Please Check All that Apply)
Congenital ROP
Degeneration
Genetic/
Has this patient had a serious illness or surgery within the past year?
Describe: ____________________________________________
Is surgery planned prior to attending VISIONS?
Type of surgery: _______________________
Please Check for Yes and X for No All that Apply)
walking
exercises fitness center/use of equipment yoga
bowling tandem bikes
lifting (i.e. horseshoes)
other__________________
swimming
sports
floor/chair
dance
May participate without restrictions
Not recommended to participate, for the following reasons:
__________________________________________________________________
__________________________________________________________________
HEALTH HISTORY
Has the patient experienced any of the following health problems?
Amputation(s) Describe: ________________________________
Asthma ..........................................................................................
Autism ...........................................................................................
Cerebral Palsy .................................................................................
Cognitive Impairment Describe: _________________________
Diabetes * .......................................................................................
Emphysema/COPD
...............................................................
Fainting/Dizziness ...........................................................................
Gait/Balance Difficulties ................................................................
Hearing Impairment .....................................................................
Hypertension/High blood pressure .................................................
Incontinence -If yes note frequency: __________________
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Patient Name___________________________
Must be completed fully by a licensed physician) (continued)
Page 2
Intellectual/Developmental Disability .........................................
Multiple Sclerosis ...........................................................................
Neurological disorder ..........................................................................
Psychiatric…………………..........................................................
Seizure Disorder .............................................................................
History of Self-Destructive Behavior.................................................
Other, Describe: _____________________________________
Yes
No
Ambulation/Support Devices?____________________
Wheelchair User?______________________________
Prosthetic Devices? ____________________________
(Describe) ____________________________________
Yes
No
* If Diabetic patient uses insulin, please provide specific orders: _______________
___________________________________________________________________
ALLERGIES
(Please List any Allergies):
___________________________________________________________________
___________________________________________________________________
Please provide specific orders and List medications required for allergic reaction
_________________________________________________________________
_____________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________
_________________________________________________________________
 Be aware that participants attending VISIONS may be required to walk or
travel more than the distance of two city blocks to dining and activity areas a
minimum of three times a day, outdoors, on uneven terrain.
Patient Name_____________________________________
Page 3
 NOTE: VISIONS will NOT provide glucose monitoring devices to participants. If
the participant is diabetic, they MUST provide their own glucose testing kit for the
duration of their stay at VISIONS from 1 to 7 days.
MEDICATIONS
(Please indicate ALL medications currently being taken along with dosage and frequency)
NAME
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
DOSAGE
PRESCRIBED TIME
HEALTH INSURANCE
Medicare # __ __ __ __ __ __ __ __ __ __ Medicaid # __ __ __ __ __ __ __ __
Sequence # __ __
Private Insurance Name _________________________________________
Private Insurance # _____________________________________________
Medical Doctor or Clinic Name __________________________________
Phone # (_______)__________________
Street Address/ City / State / Zip
________________________________________ ________________ _______ ______
Eye Doctor or Clinic Name __________________________________
Phone # (_______)__________________
Street Address/ City / State / Zip
________________________________________ ________________ _______ ______
Patient Name_____________________________________
Page 4
ANNUAL PHYSICIAN ORDER
FOR OVER-THE-COUNTER (OTC) MEDICATION ADMINISTRATION
TO ALL PARTICIPANTS AT VISIONS
Medications/Treatments
Acetaminophen (Tylenol) 650 mg
____Adult
____Children
Non-Narcotic Antitussive
(Robitussin)
Cough drops (sugarless) for Diabetic
Cough drops
Alum/Magnesium Hydroxide Liquid
with simethicone (eg. Mylanta)
Pepto Bismol Liquid
Imodium Liquid
Milk of Magnesia
Bacitracin
Calamine
Benadryl
____Adult
____Children
Administration Directions
Yes No
ADULT: 2 tabs, po, q4h, up to a maximum of 12
tabs in 24 hrs. PRN for headache, toothache,
backache, muscular aches, minor arthritis pain,
elevated temps (above 100), menstrual pain.
CHILDREN: Under 6 yrs – consult doctor,
6 – 11 yrs of age 2 teaspoons, po,q6h
Two tsp., po, q4h. PRN for cough. Not to exceed 12
tsp. In 24hrs.
1 drop, po, q1h for cough.
1 drop, po, q1h for cough.
30cc, po. PRN for acid indigestion, heartburn, sour
stomach, or flatulence.
30cc, po. PRN for nausea, heartburn, upset stomach,
and diarrhea.
30cc, po. PRN for first episode of diarrhea and if
continues then 10cc.
30cc po. PRN for constipation followed by 8 oz of
water.
500 units. PRN for minor cuts, wounds, burns, and
abrasions.
Apply freely. PRN for itching due to insect bites or
other minor skin irritations.
ADULT: Age 12 yrs to Adult, 2 - 4 tsp, po
CHILDREN: Age 6-12 yrs, 1 - 2 tsp, po
Doctor’s Name (Print)______________________________________
Phone (
)______________________________________ Ext.________
Address_______________________________________ Zip___________
Doctor’s Signature________________________________ Date_________
* Please Note: Doctor’s License stamp or medical facility stamp MUST be
included with signature. Medical form will not be accepted without it.
Rev. 11/27/13 RC