Nyc physical exam form

    • [PDF File]TINETTI BALANCE & GAIT ASSESSMENT -Physical ...

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      PT, Tinnetti Balance Assessment: 7/09 Riskof Fal: 18 Po ntr Le =Hgh ,9- 23 Md r4 P w AF IXSTCKER TINETTI BALANCE & GAIT ASSESSMENT For both assessments, enter the date of each exam and circle your rating for each item. Indicate totals at the bottom of each section.

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    • [PDF File]TINETTI BALANCE ASSESSMENT TOOL

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      TINETTI BALANCE ASSESSMENT TOOL GAIT SECTION Patient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace. Risk Indicators: Tinetti Tool Score Risk of Falls ≤18 High 19-23 Moderate ≥24 Low Date Indication of gait (Immediately after told to ‘go’.) Any hesitancy or multiple attempts = 0 No hesitancy = 1

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    • [PDF File]COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)

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      Columbia-Suicide Severity Rating Scale (C-SSRS) The Columbia-Suicide Severity Rating Scale (C-SSRS) is a questionnaire used for suicide assessment developed by multiple institutions, including Columbia University, with NIMH support. The scale is

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    • [DOC File]Aid Codes Master Chart (aid codes) - Medi-Cal

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      The Aid Codes Master Chart was developed for use in conjunction with the Medi-Cal Automated Eligibility Verification System (AEVS). Providers must submit an inquiry to AEVS to verify a recipient’s eligibility for

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    • [PDF File]MEDICAL REQUEST FOR HOME CARE HCSP- M11Q ... - New York City

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      treatment to the New York City HRA/ Dept. of Social Services in connection with my request for home care. ... Signature date must be within thirty days after medical exam of patient. ... * Please provide this sheet to the physician filling out the Medical Request for Home Care (M-11Q). Eight Helpful Hints for Accurate Completion of the ...

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    • [PDF File]Form I-693, Report of Medical Examination and Vaccination ...

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      Form I-693 07/15/19. Page 1 of 14. Report of Medical Examination and Vaccination Record . Department of Homeland Security . U.S. Citizenship and Immigration Services . USCIS Form I-693 . OMB No. 1615-0033 ... Physical Address 3. Street Number and Name Apt. Ste. Flr. Number City or Town.

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    • [PDF File]NICHQ Vanderbilt Assessment Scale—PARENT Informant

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      When completing this form, please think about your child’s behaviors in the past 6 months. Is this evaluation based on a time when the child was on medication was not on medication not sure? Symptoms Never Occasionally Often Very Often

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    • [PDF File]CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

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      certificate holder © 1988-2010 acord corporation. all rights reserved. acord 25 (2010/05) authorized representative cancellation certificate of liability insurance ...

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    • [PDF File]Form N-648, Medical Certification for Disability Exceptions

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      Form N-648, Medical Certification for Disability Exceptions. ALL parts of this form, except the "APPLICANT ATTESTATION" and "INTERPRETER'S CERTIFICATION" must be certified by a licensed medical professional as provided in the instructions for Form N-648. Before certifying this form, the medical professional must

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    • [PDF File]Form ST-124:(12/15):Certificate of Capital Improvement:ST124

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      Form ST-120.1, Contractor Exempt Purchase Certificate. (See Publication 862 for additional information.) The term materials is defined as items that become a physical component part of real or personal property, such as lumber, bricks, or steel. This term also includes items such as doors, windows, sinks, and furnaces used in construction.

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