Patient Assessment
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Admitted From:
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Case Manager:
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Social Worker:
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Expressed Concerns:
________________________________
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Family Spokesperson:
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Contact
________________________________
Email:
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What brought you in to see me today?
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Do you have a doctor or other provider you see for general medical needs?
[__] Yes [__] No
Primary Care:
Name:
________________________________
Address: _________________________
City: __________ State: ___ Zip: ____
Phone:
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Date of Last Visit:
____/____/______
Health Concerns:
________________________________
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Have you talked to a doctor about these health concerns?
[__] Yes [__] No
How would you rate your general state of health?
[__] Excellent
[__] Good
[__] Fair
[__] Poor
How often do you see your doctor?
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Do you have health insurance?
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Are you working?
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Financial Issues?
________________________________
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Are you interested in finding employment?
[__] Yes [__] No [__] Not Sure
Do you do any volunteer work?
[__] Yes [__] No
Are you interested in doing any community or volunteer work?
[__] Yes [__] No
If yes, please describe:
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What is the highest level of formal education that you have completed?
[__] High School
[__] College
[__] Graduate School
Are you interested in going back to school?
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Housing Status:
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Housing Concerns:
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Client Signature:
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Case Manager:
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Date: ____/____/______
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