Annual Physical Form

* = Required Information

* This form to be used for Annual Physicals Only

Resident: *

Appointment Date: *

Doctor/Location:

Appointment Time:

Primary Diagnosis:

Date of Birth:

Staff Attending Appt:

Diet:

Allergies:

Current Medications (including topical and PRN medications): Fill out below OR attach a copy of the MAR’s.

Medication/Treatment

Dose/Frequency/Route

Reason for Use

Medication/Treatment

Dose/Frequency/Route

Reason for Use

Medication/Treatment

Dose/Frequency/Route

Reason for Use

Current concerns:

*Above to be completed by A Helping Hand Senior Care Services staff*

*Below to be completed by the Physician or Health Care Professional*

Height:

Wt:

Temp:

Pulse:

Blood Pressure:

Date of Tetanus Booster:

General Health:

Excellent

Good

Fair

Poor

This person is free from communicable diseases.

Yes

If endangering self or others, is a manual restraint medically contraindicated?

Yes

Is the annual flu vaccine recommended?

Yes

May take supervised leaves with medication

Yes

Are alcoholic beverages contraindicated?

Yes

This person may administer their own medications.

Yes

A Helping Hand Senior Care Services nurse has permission to adjust administration times.

Yes

MD notified of medication errors at nurse’s discretion.

Yes

Please provide details regarding when and what to report:

Summary of examination and lab work completed:

New Orders: (Print clearly OR attach electronic signed orders):

Next Appointment Date:

Physician’s Printed Name: *

Date: *

Standing Orders for Over-the-Counter Medications

Name:

Allergies:

The following may be given on a PRN (as needed) basis. Medications contraindicated will be noted by the physician. Equivalent generic or store brands may be used. Follow all instructions as listed. Chart medications administered on the Medication Administration Record (MAR). Document the reason for giving the medication and the resident’s response to the medication in the Health Progress Notes.

Fever/Pain:

(one of the following medications may be given. Once one of the following is chosen, give only that medication at the intervals listed)

Tylenol (Acetaminophen) – 500 mg 2 tablets every 4 hours as needed for fever or discomfort. Do not crush.

Tylenol Elixir (Acetaminophen) – 2 Tablespoons (30 cc) every 4 hours as needed for fever or discomfort. Do not exceed 8 Tablespoons in 24 hours.

Ibuprofen – 200 mg 2 tablets every 4 hours as needed. Do not exceed 6 tablets in 24 hours.

Cold/Cough:

(one of the following medications may be given. Once one of the following is chosen, give only that medication at the intervals listed. Throat lozenge may be given with the one other medication chosen/given)

Tylenol (Acetaminophen) – 2 Tablespoons (30 cc) every 4 hours as needed for fever or discomfort. Do not exceed 8 Tablespoons in 24 hours.
Sudafed PE (Phenylephrine HCl) – 10 mg. 1 tablet every 4 hours as needed for nasal congestion. Do not exceed 6 tablets in 24 hours.
Robitussin DM (Dextromethorphan and Guaifenesin) – 2 teaspoons (10 cc) every 4 hours as needed for cough. Do not exceed 6 doses in 24 hours.
Chloraseptic Lozenges – one lozenge as needed for sore throat. Follow package directions.
Note: Avoid dairy products, high fiber foods, and caffeine. Give clear liquids, such as water, 7-Up, Gatorade, popsicles, Kool-aid, or apple juice.

Constipation:

Milk of Magnesia – 2 Tablespoons as bedtime as needed.

Diarrhea:

Imodium (Loperamide) – 2 mg. 2 tablets after 1st loose bowel movement, followed by 1 tablet after each subsequent bowel movement. Do not exceed 4 tablets per day. Do not use for more than 2 days.

Indigestion/Heartburn:

(one of the following medications may be given. Once one of the following is chosen, give only that medication at the intervals listed)

Maalox (Alumina and Magnesium) – 1 Tablespoon (15 cc) every 3-4 hours as needed.
TUMS Regular Strength (Calcium carbonate USP 500 mg) – Chew 2 tablets every 3-4 hours as needed. Do not exceed 15 tablets in 24 hours.

Poisoning:

Call Poison Control Immediately: 1-800-222-1222

Minor Wounds/Cuts:

(one of the following medications may be given. Once one of the following is chosen, give only that medication at the intervals listed)

Bacitracin Ointment – Apply a small amount to wound 1-3 times daily as needed. Do not use on deep wounds, puncture wounds, or burns unless directed by a physician.

Mild sunburn/insect bites/minor skin irritation (i.e. Poison Ivy/Oak) :

Calamine Lotion – apply liberally 3-4 times daily as needed. Before each application, clean area with soap and water and dry thoroughly; shake bottle well.

Rashes/skin inflammation:

1% Hydrocortisone Cream – Apply 3-4 times daily as needed. Do not apply to an area larger than 10”X10” unless directed by a physician. Avoid contact with eye area and mouth.

Athlete’s Foot:

Micatin (Miconazole) – Apply cream sparingly to affected areas, including between toes, twice daily. Massage in well.
Note: Ensure that resident’s feet are washed and dried well daily. Encourage use of clean, white, cotton socks. Consult physician if condition persists for more than 2 weeks.

Dandruff:

Selsun Blue (Selenium Sulfide) Shampoo – Use 1-2 times per week as needed for dandruff. Shake well before use. Apply, lather, rinse, and repeat. Rinse well. Avoid getting into eyes.

Dry Skin:

May use non-medicated hygiene/grooming products designed for dry skin as needed or as directed by nurse.

Chapped Lips/Cold Sores:

Carmex – apply to lips 2-4 times daily as needed for chapping, fever blisters, or cold sores.
Bliste - apply to lips 2-4 times daily as needed for chapping, fever blisters, or cold sores.
May use non-medicated hygiene/grooming products as needed or as directed by nurse.

Prevention:

Sunburn – use sunblock with SPF of 15 or greater. Follow directions on bottle
Insect bites – Deep Woods Off (insect repellant with DEET). Follow package directions.

Other:

WHEN TO CONTACT THE NURSE

Notify nurse if you have ANY questions about passing the standing orders/over-the-counter medication.

Notify nurse of a temperature is above 100°F or if pain is not relieved by medication.
Notify nurse if a person experiences persistent cough, persistent diarrhea, earache, painful urination, congestion, vomiting, swelling, difficulty breathing, has not had a bowel movement for 3 days (or within 24 hours of using a laxative) or skin rash.
Notify nurse if the person is reporting chest pain.

If the person served is unconscious, call 911 immediately.

Physicians Name: *

Date: *