FARNUM CENTER
140 Queen City Ave.
Manchester, NH 03103
Phone (603) 622-3020
Fax (603) 622-4043
WEBSTER PLACE
27 Holy Cross Road
Franklin, NH 03235
Phone (603) 934-2020
Fax (603) 934-9815
*Webster Place requires physical evaluation
within 24 hours prior to admission
Easter Seals NH Substance Abuse Services
Physician’s Waiver
____________________________________________________________________________________________________
Last Name
First Name
DOB
____________________________________________________________________________________________________
Address
City
State
Attending Physician: __________________________________________
Diagnosis: ______________________________
Height: _______________________
Weight: ______________________
Temperature: ______________________
Pulse: ________________________
Respiration: ___________________
Blood Pressure: ____________________
HISTORY SEE DETOX HISTORY
Medical History: _____________________________________________________________________________________
____________________________________________________________________________________________________
Psychosocial History: _________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
PHYSICAL EXAMINATION SEE DETOX EXAM
Is client is able to perform physical activities without restriction? ____________________________________________
____________________________________________________________________________________________________
General Appearance – Nutrition – Pallor: _________________________________________________________________
____________________________________________________________________________________________________
Head – Eye – Ear – Nose – Throat: ______________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Heart: Is murmur present? _________________________ Is there enlargement? __________________________________
Lungs: Normal respirations? _________________________Rates: _________________Dullness:______________________
Abdomen: Distention: _________________________________________________________________________________
Enlarged spleen? __________________________________________________________________________
Enlarged liver? ____________________________________________________________________________
Adenopathy:
Neck: _________________________________________________________________________________
Axilla: ________________________________________________________________________________
Groin: ________________________________________________________________________________
Extremities – Bones – Joints: ___________________________________________________________________________
____________________________________________________________________________________________________
Neurological:
DTR’s, Babinski, Romberg: _____________________________________________________________
Cranial Nerves: _______________________________________________________________________
Gait: ________________________________________________________________________________
Balance: _____________________________________________________________________________________________
Coordination Motor Strength: ____________________________________________________________________________
URINALYSIS
Possitive for (please include all) : ________________________________________________________________________
____________________________________________________________________________________________________
The following diagnostic tests should be performed as part of the physical if indicated:
EKG
Electrolytes
CBC and Differential
Blood Sugar
Liver Function
The written results of these tests are to be forwarded to the Farnum Center and/or Webster Place as soon as available.
Special Dietary Needs: _________________________________________________________________________________
Allergies: ____________________________________________________________________________________________
*Please include medical records and full list of current prescriptions. If the medication is not listed or
does not have a written medical order client will not be able to take medication.
Medication Rx Checklist
Medication Name
Medication Purpose
Dosage
Date
Filled
PLEASE SEE DETOX
DISCHARGE
ORDERS
# Refills
Remaining
Client may also take the following “non-prescribed medications” if needed and according to the package
directions while in residence at the Farnum Center and/or Webster Place (Physician should CROSSOUT if
client MAY NOT take any of the below medications.)
Aspirin, non-aspirin, ibuprofen/Advil, liquid antacid, cough drops, multivitamins,
Cortaid/hydrocortisone cream, anti-fungal cream (athlete’s foot), Sudafed (pseudoephedrine), cold
or allergy medication, medicated foot powder, Tums/Rolaids, hydrogen peroxide (topical antiinfective), Neosporin or comparable antibiotic cream, Antiseptic wipes, Milk of Magnesia, Colace,
Anbesol/Orajel
Please Note: Preapproval by a residents PCP provides our program with a qualified opinion that the
resident is capable of physical and mental participation in all aspects of our program. Easter Seals NH
does not provide medical treatment or detoxification and should not be viewed as a substitute for those
services.
This is to certify that I have examined _________________________________ on ________________
and find him/her to be free of communicable diseases and not in need of nursing care. There are no overt
withdrawal symptoms present during this examination that require hospitalization. She/he is mentally
competent, not suicidal and is oriented to person, place, and time, ambulatory and capable of full self-care.
I certify that the enclosed information is accurate.
______________________________________
Physician Signature
______________________________
Date