Physician Agreement

Katie Adult Day Care is a licensed adult day center providing a program of therapeutic social, health, and
recreational activities for adults. A nutritional noon meal and morning and afternoon snacks are served with
consideration for special diets. We also regularly provide to our participants the services of a Registered Nurse,
Registered Dietician, and Therapeutic Recreation Specialists. In addition, with a written Physicians Order, we
may provide specific medical care such as skilled nursing care, foot care, medication administration and/or
rehabilitation services such as Occupational, Physical, and Speech Therapy.
Your patient has been referred for admission to our program. In order for your patient to attend we must have
the enclosed information signed and on file upon admission per our licensing standards (MN Rule 9555.9660
Part B). A signed release for this information has been enclosed. Your cooperation in filling this out and
returning it promptly will help us to offer the best services possible to your patient. Thank you!
Patient's Name: _____________________________________________ Date of Birth: __________________________
Address: ________________________________City_______________________________State_________Zip___________
Date of last physical examination: _______________________________________________________________________
PRIMARY HEALTH PROBLEMS and CURRENT DIAGNOSIS:
Please indicate if the above-named person has any of the following diseases or conditions. If so, please indicate also whether
or not the condition requires any special attention or restricts normal activities.
Current Disease / Special Attention Required/ Current Disease / Special Attention Required/
Yes Chronic Condition Restrictions on Activities Yes Chronic Condition Restrictions on Activities

Alzheimers disease____________________________ Epilepsy____________________________________

Amyotrophic lateral sclerosis ____________________
Anemia______________________________________
Anxiety______________________________________
Arthritis_____________________________________
Cancer_______________________________________
Cerebral Palsy_________________________________
Congestive Heart Failure_________________________
Delirium_____________________________________
Dementia_____________________________________
Seizures_____________________________________
Depression____________________________________
Developmental Disability________________________
Diabetes______________________________________
Edema________________________________________
Effects of Stroke, Paralysis________________________
Emphysema, Chronic Bronchitis___________________
Fainting Spells_______________________________
Fractures____________________________________
Gastro-Intestinal Problems______________________
Heart Disease________________________________
Hypertension_________________________________
Hypotension_________________________________
Kidney Disease_______________________________
Parkinsons Disease___________________________
Skin Disorders, specify: ________________________
Tuberculosis_________________________________
Ulcers______________________________________
Urinary Incontinence__________________________
Other______________________________________
Other______________________________________

HEALTH HISTORY (past surgeries, hospitalizations, etc.):__________________________________________________

_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

Adult Day Services Policies and Procedures Manual 10-006.16

___________________________________________________________________________________________________
Patient's Name: _____________________________________________ Date of Birth: __________________________

GENERAL HEALTH STATUS OF PATIENT:

Adult Day Services Policies and Procedures Manual 10-006.16

Vision ________________________ Hearing _________________________ Speech ________________________
Special Diet? (If so, provide detailed information) __________________________________________________________
Allergies? (food, medications, bee stings, etc.):
_____________________________________________________________
Does this patient have any communicable diseases? Yes ________ No ________
Under the supervision of qualified staff, could this patient participate in a structured exercise program?
Yes ____ No ____ - Comment: ________________________________________________________________
MEDICATION REQUIREMENTS (including over-the-counter and herbal remedies currently being taken)
Please list below OR Include a printout of medications:
Name of Medication Condition being Treated Dosage requirements
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Is this client physically capable of independently taking and swallowing medications? Yes_______ No_______
Is this client cognitively capable of independently taking and swallowing medications? Yes_______ No_______

STANDING ORDERS FOR MEDICATION AND TREATMENT (please check those you approve of these
are reviewed annually):
This person may take 2 tablets of Tylenol (500 mg each) PRN for comfort.
This persons minor wounds may be treated by cleansing with normal saline, application of antibiotic
ointment and dressing.

Meal/snack portion size may be half or full per client/family request.

If client is diabetic:
Client requires blood glucose monitoring during care center hours (9a-3p) designate specific
order (skilled nursing charges apply to this procedure):
_________________________________
Diet order: ____________________________________________________________________

Any other special medical precautions, other restrictions or limitations? _________________________________________

___________________________________________________________________________________________________
I certify that I have examined the above-named person and have reviewed their health history, and find him/her physically
able to participate in an adult day health activity program.

Signature of Physician: ____________________________________________________ Date: _____________________

Please Print Physician Name: ________________________________________________________

Thank you for providing this information.

34 Tenth Avenue South, Hopkins, Minnesota 55343-7506

Telephone 952.935.8143 Fax 952.935.0229 Website www.opencircle.org