ࡱ>  Rdbjbj %__N~ ~ Dt Px p':R'R'R'?p AA\OOOOOOO$RUP9B>|z?"BBPR'R':P|F|F|FBRR'8R'O|FBO|F|FVL@b"Lp xBjL OPP0PL VPC~VLVLBB|FBBBBBPPDBBBPBBBBVBBBBBBBBB~ X : CLIENTS NAME:EMAIL ADDRESS:MAILING ADDRESS:CITY:STATE:ZIP:HOME PHONE:WORK PHONE:CELL PHONE:DATE OF BIRTH:INSURANCE: PHYSICAL EXAM HOW LONG HAVE YOU ATTENDED PATIENT?FIRST VISIT:AGE:HEIGHT:WEIGHT:GENDER (M / F):B/P:HEART RATE:CAUSE OF BLINDNESS:GAIT:Normal: FORMCHECKBOX Abnormal: FORMCHECKBOX SENSORY:Normal: FORMCHECKBOX Abnormal: FORMCHECKBOX COORDINATION:Normal: FORMCHECKBOX Abnormal: FORMCHECKBOX FEET:Normal: FORMCHECKBOX Abnormal: FORMCHECKBOX REFLEXES:Normal: FORMCHECKBOX Abnormal: FORMCHECKBOX  MEDICAL HISTORY ENDOCRINE:YESNODiabetes/Type/Years FORMCHECKBOX  FORMCHECKBOX HbA1c Value / DateInsulin Reactions/Severity FORMCHECKBOX  FORMCHECKBOX Neuropathy FORMCHECKBOX  FORMCHECKBOX Hypoglycemia FORMCHECKBOX  FORMCHECKBOX Hyperglycemia FORMCHECKBOX  FORMCHECKBOX Thyroid FORMCHECKBOX  FORMCHECKBOX Explain:MUSCULAR/SKELETAL:Amputations FORMCHECKBOX  FORMCHECKBOX Back Injury FORMCHECKBOX  FORMCHECKBOX Dislocations FORMCHECKBOX  FORMCHECKBOX Fractures FORMCHECKBOX  FORMCHECKBOX Foot/Knee Injury FORMCHECKBOX  FORMCHECKBOX Arm/Shoulder/Wrist Injury FORMCHECKBOX  FORMCHECKBOX Muscle/Skeletal Disease FORMCHECKBOX  FORMCHECKBOX Explain:NEUROLOGICAL:Seizures/Type/Frequency FORMCHECKBOX  FORMCHECKBOX Date of Last SeizureHead Injury FORMCHECKBOX  FORMCHECKBOX Headache/Frequent FORMCHECKBOX  FORMCHECKBOX Migraines FORMCHECKBOX  FORMCHECKBOX Ear Disorder FORMCHECKBOX  FORMCHECKBOX Explain:GI/GU:YESNOObesity FORMCHECKBOX  FORMCHECKBOX Ulcers FORMCHECKBOX  FORMCHECKBOX GERD FORMCHECKBOX  FORMCHECKBOX Kidney/Bladder Disease FORMCHECKBOX  FORMCHECKBOX Liver/Gallbladder Disease FORMCHECKBOX  FORMCHECKBOX Rectal Problems FORMCHECKBOX  FORMCHECKBOX Explain:CARDIAC:Heart Surgery FORMCHECKBOX  FORMCHECKBOX Heart Attack FORMCHECKBOX  FORMCHECKBOX Hypertension FORMCHECKBOX  FORMCHECKBOX Hyperlipidemia FORMCHECKBOX  FORMCHECKBOX Arrhythmia FORMCHECKBOX  FORMCHECKBOX Dizziness FORMCHECKBOX  FORMCHECKBOX Syncope FORMCHECKBOX  FORMCHECKBOX Shortness of Breath FORMCHECKBOX  FORMCHECKBOX Palpitations FORMCHECKBOX  FORMCHECKBOX Anemia FORMCHECKBOX  FORMCHECKBOX Blood Disorder FORMCHECKBOX  FORMCHECKBOX Fatigue/Chronic FORMCHECKBOX  FORMCHECKBOX Explain:INTEGUMENTARY:Skin: Rash / Hives FORMCHECKBOX  FORMCHECKBOX Explain:PULMONARY:YESNOLung Disease FORMCHECKBOX  FORMCHECKBOX Tuberculosis FORMCHECKBOX  FORMCHECKBOX Cough FORMCHECKBOX  FORMCHECKBOX Asthma FORMCHECKBOX  FORMCHECKBOX Allergies FORMCHECKBOX  FORMCHECKBOX O2 Use/CPAP FORMCHECKBOX  FORMCHECKBOX Explain:MENTAL HEALTH:Diagnosed Mental Illness FORMCHECKBOX  FORMCHECKBOX Depression FORMCHECKBOX  FORMCHECKBOX Anxiety FORMCHECKBOX  FORMCHECKBOX Dementia/Memory FORMCHECKBOX  FORMCHECKBOX Sleep Disorder FORMCHECKBOX  FORMCHECKBOX Eating Disorder FORMCHECKBOX  FORMCHECKBOX Substance Abuse/Recovery FORMCHECKBOX  FORMCHECKBOX Tobacco FORMCHECKBOX  FORMCHECKBOX Explain:OTHER:Transplants FORMCHECKBOX  FORMCHECKBOX Explain: ANY ILLNESS OR INJURY REQUIRING HOSPITALIZATION IN THE PAST THREE (3) YEARS? EXPLAIN:MEDICAL HISTORY/NARRATIVE:MEDICATIONS/DOSAGEDIRECTIONSSTART DATE (APPROX)MED ALLERGIES / REACTION:FOOD ALLERGIES / REACTION:SPECIAL DIET/DIETARY RESTRICTIONS (If applicable):REGULAR DIET: FORMCHECKBOX ATTACH RECENT LAB WORK DONE AND THE RESULTS (OR SUBMIT A COPY): WITHIN 1 YEARTB/PPD TEST:PLEASE COMPLETE PG.3 FOR LTBI RISK ASSESSMENT. IF LTBI TESTING IS INDICATED, TEST IS MANDATORY AND MUST BE CURRENT WITHIN 18 MONTHS OF PATIENT'S TRAINING START DATE.NEGATIVE FORMCHECKBOX POSITIVE FORMCHECKBOX DATE:NOT INDICATED FORMCHECKBOX CHEST XRAY (only if TB/PPD positive):NORMAL: FORMCHECKBOX ABNORMAL: FORMCHECKBOX DATE:TETANUS: FORMCHECKBOX DATE:OTHER INFORMATIONHEARING:Normal: FORMCHECKBOX Abnormal: FORMCHECKBOX HEARING AIDSYes FORMCHECKBOX No FORMCHECKBOX L FORMCHECKBOX R FORMCHECKBOX This is a Two-week residential training program that requires sustained cognitive, physical, emotional and social functioning from 6 am until 9 pm. Students must be reasonably independent with chronic disease management, and demonstrate normal immunity to dormitory life. They must be able to walk up to one hour twice a day with their dog, and will experience a definable pull from the dog in harness on their left side during the walk.(YES FORMCHECKBOX NO FORMCHECKBOX DO YOU HAVE ANY CONCERNS ABOUT THIS INDIVIDUAL PARTICIPATING IN THIS PROGRAM WITH MINIMAL INTERVENTION AND ASSISTANCE?((YES FORMCHECKBOX NO FORMCHECKBOX HAVE YOU DISCUSSED YOUR PATIENTS COVID-19 RISK FACTORS (IF APPLICABLE) WITH THEM?(PHYSICIANS SIGNATUREDATEPHYSICIANS NAME (please print)SPECIALTYADDRESSTELEPHONE:FAXE-MAIL California Adult Tuberculosis Risk Assessment Use this tool to identify asymptomatic adults for latent TB infection (LTBI) testing. Do not repeat testing unless there are new risk factors since the last test. Do not treat for LTBI until active TB disease has been excluded: For patients with TB symptoms or an abnormal chest x-ray consistent with active TB disease, evaluate for active TB disease with a chest x-ray, symptom screen, and if indicated, sputum AFB smears, cultures and nucleic acid amplification testing. A negative tuberculin skin test or interferon gamma release assay does not rule out active TB disease. LTBI testing is recommended if any of the boxes below are checked.Birth, travel, or residence in a country with an elevated TB rate for at least 1 month Includes any country other than the United States, Canada, Australia, New Zealand, or a country in western or northern Europe If resources require prioritization within this group, prioritize patients with at least one medical risk for progression (see the California Adult Tuberculosis Risk Assessment User Guide for this list). Interferon Gamma Release Assay is preferred over Tuberculin Skin Test for non-U.S.-born persons e"2 years old Immunosuppression, current or planned HIV infection, organ transplant recipient, treated with TNF-alpha antagonist (e.g., infliximab, etanercept, others), steroids (equivalent of prednisone e"15 mg/day for e"1 month) or other immunosuppressive medicationClose contact to someone with infectious TB disease during lifetimeTreat for LTBI if LTBI test result is positive and active TB disease is ruled out.None; no TB testing is indicated at this time.  See the California Adult Tuberculosis Risk Assessment User Guide for more information about using this tool. To ensure you have the most current version, go to the  HYPERLINK "https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/TB-Risk-Assessment.aspx" TB RISK ASSESSMENT page (https: HYPERLINK "http://www.cdph.ca.gov/Programs/CID/DCDC/Pages/TB-" //www.cdph.ca HYPERLINK "http://www.cdph.ca.gov/Programs/CID/DCDC/Pages/TB-" .gov/Pr HYPERLINK "http://www.cdph.ca.gov/Programs/CID/DCDC/Pages/TB-" ograms/CID/DCDC/Pages/TB- Risk-Assessment.aspx)      National Office: P.O. 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