LOCAL INTAKE ASSESSMENT - Section 5 - Medical Information

Local Full Name

First Name

Last Name

Local Height

Local Weight

Diagnoses and Date of Diagnoses for Each

Comments

Medications

Refills Up to Date

All medications must have at least 60 day supply before entering the Southwind Fields community

Yes

Locals MUST be able to take medications independently and communicate any medication needs to Wellness Director. Can the Local take their medications independently?

What methods does Local use to remember to take medications?

This should include over the counter medications or prescriptions received when sick

What happens if a prescribed medication is missed?

Medical Devices

Heaing Aide, Shunt, Pacemaker, VNS Spinal Rod, etc.)

Adaptive Equipment

Speech Board, ane, Walker, Wheelchair, Scooter)

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SOUTHWIND FIELDS IS A NONPROFIT 501(C)3 ORGANIZATION

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