Hospice Intake Addendum

Individual’s Name: / Likes to be called:
Birth Date: / Soc. Sec. No.:
Address:
Telephone Number: / Religion:
Health Insurance:
(Type and Numbers) / Primary:
Secondary:
Agency Responsible for Care: / No Yes / If Yes, List Name of Agency:
Agency Point Person:
Agency Telephone Number:
Nursing Support: / No Yes / If Yes, List Name of Agency:
Day Program: / Type of Day Program:
Day Program Contact Person:
Nursing Support: / No Yes / If Yes, List Name of Agency:
DDS
Area Office: / DDS/Area Office Nurse:
Service Coordinator: / Telephone Number:
Consent Status: / Can Give Own Consent
Consent from Guardian / Guardian Name: / Telephone Number:
Unable to give Own Consent and No Guardian
Resuscitation Status: / DNR
Full Resuscitation / If DNR, is Comfort Care form available? / No Yes Unknown
Health Care Proxy: / No
Yes / Proxy Name: / Telephone Number:
Emergency Contacts / Allergies
Name: / Medications:
Telephone Number: / Food/Environmental:
Name: / Type of Reaction:
Telephone Number:
Medications: / Medication Sheet/Record Attached
List Attached / Current Medical Problems and Diagnoses:
Pharmacy Name:
Pharmacy Address:
Telephone Number:
Communication: / Able to Communicate / Communication Difficulties/ Uses Verbalizations / Communication Difficulties/ Uses Gestures / Not able to Communicate Needs
Unable to use Call Bell / Only Speaks/ Understands Foreign Language / Unknown
Vision: / Normal / Low Vision / Blind / Wears Glasses
Unknown
Hearing: / Normal / Hard of Hearing / Deaf / Hearing Aid
Unknown
Supportive Devices: / Padded Side Rails / Splints / Braces / Helmet
Other: / Unknown / None
Toileting Ability: / Continent / Needs Assistance / Incontinent / Catheterized
Other: / Unknown
Medication Administration: / Independent/Self-Administers / Medicated by Staff / Other
Dining/Eating: / Independent / Needs Assistance / Totally Dependent / Fed Through Tube
Other / Unknown
Diet Texture: / Regular / Chopped / Ground / Puree
Thicken Liquid / Other
Diet Type:
Ambulation: / Independent-Steady / Independent-Unsteady / Needs Assistance (1 person) / Needs Assistance (2 people or more)
Ambulation Aids- Walker / Ambulation Aids- Cane / Ambulation Aids- Crutches / Ambulation Aids- Wheelchair
Non-Ambulatory / Other: / Unknown
Personal Hygiene: / Independent / Special Needs / Other
Oral Hygiene: / Independent / Special Needs / Other
Head of Bed Elevated? / No / Yes
Special Needs: / Behavior/Rituals:
Likes:
Dislikes:
Special Communication Device/Method:
Pain Response: / Typical / Unique
Please Explain:
Health Care Providers / Telephone / Fax
Type/Specialty / Name / Street Address / City / State / Zip / Number / Number
Primary Care
Dental Care
Eye Care
Additional Information:
Completed By: / Date:
Relationship to the Individual: