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Visit Data | Patient Personal Data | Volunteer Data | Chief Complaint, Diagnosis, ICD-9 | Plan | Notes

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Visit Data

Date: Medical Record #:

Patient Personal Data

Last Name
First Name
Middle Initial
Address
City
State
ZIP
Phone - -
Birthdate / /
Sex


Demographic Data White
Black/African American
Latino
Vietnamese
Non-Vietnamese Asian/Pacific Islander
Native American
Other
Type of Housing Own/Rent
With Family/Friends
Public Housing
Shelter/Group/Transitional Home
Homeless - How many months?
No Response
Do you have heath insurance? Yes
No
No Response
If yes, Medicare
MediCal
Healthy Families
Healthy Kids
Private
Well
Medicaid
Other
Are you a veteran? Yes
No
No Response
Employment Status Unemployed
Employed - Occupation
No Response
Size of Household?
Annual Household Income?
Highest Level of Education Elementary School or less
Middle School
High School
Some College
College
Graduate School
Other Degree/Certification
No Response
Known Drug Allergies?
HIPAA Notice of Privacy Practices Signed?

Volunteer Data

Patient Advocate:
Physician:
Was an interpreter used? Yes
No
No Response
Interpreter:
What language? Spanish
Chinese
Vietnamese
Tagalog
Other:
Tongan
No Response

Chief Complaint, Diagnosis, ICD-9

Chief complaint(s)
MDSkolar ICD9 search
Diagnosis ICD-9
Diagnosis ICD-9
Diagnosis ICD-9
Diagnosis ICD-9
Diagnosis ICD-9

Plan

Interventions Procedure
Medications
Labs
Referrals
Social Services
Education
Medications Rx Lot# Voucher# Dosage Frequency Duration
Rx Lot# Voucher# Dosage Frequency Duration
Rx Lot# Voucher# Dosage Frequency Duration
Rx Lot# Voucher# Dosage Frequency Duration
Labs Lab Name:
Lab Notes:
Referrals Chaboya Clinic Gardner Clinic Health Trust La Leche League
EVCC CompreCare Family Health Found. Arbor Crane Clinic
Stanford ER Valley Medical Center San Mateo Gen Planned Parenthood
Other
Referral Reason
Social Services CompreCare VN-Amer Cultural & Social Council Narvaez Public Health
Almaden Valley Community Assoc. American Cancer Society YWCA
Economic & Social Opportunities Resources for Family & Community
Benefits Analyst Other

Notes

Chart Notes / Follow-Up / PAP: