Medical history and admission examination - DPHHS Home 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the attending physician's last and first name in the designated fields. Ensure accuracy as this information is crucial for your admission process.
3. Fill out the admission diagnosis section fully, providing a clear description of the applicant's condition.
4. Complete the past immunization history, including PPD details and any influenza or pneumococcal vaccinations. Be sure to indicate whether treatments were administered.
5. Provide summaries of present and previous illnesses, detailing any significant medical history that may affect care.
6. List all current medications along with dosages and any known allergies in the respective sections to ensure comprehensive medical oversight.
7. Assess functional capabilities by marking whether the applicant can perform daily activities independently or requires assistance.
8. Finally, ensure all sections are completed before signing and submitting the form for review.

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