Healthcare Adult Day Health Form

Healthcare Adult Day Health Form

Client Information

Date of Birth:    Gender: Male Female Other Prefer not to state

Emergency & Authorized Contacts

Insurance & Coverage

Primary Care & Medical Contacts

Medical History & Current Health Status

Current Medications (include dose & frequency):

Medication Allergies and Reactions:

Prior Surgeries / Hospitalizations (with approximate dates):

Chronic Conditions (check all that apply): Diabetes Hypertension Heart disease COPD / Asthma History of stroke Dementia / Cognitive impairment Seizure disorder Mobility impairment Other

Functional Abilities

Ambulation: Independent Needs assistance Dependent

Toileting: Independent Needs assistance Dependent

Eating: Independent Needs assistance Dependent

Nutrition / Swallowing

Diet restrictions (therapeutic diet, textures):

Swallowing or aspiration risk: No Yes — if yes, describe

Medications Administration

I authorize the adult day health program to administer medications per the provider's written orders and to maintain a medication administration record (MAR). I understand staff will follow documented instructions and will notify the prescriber and family of significant changes.

Emergency Medical Authorization

In the event of an emergency, I authorize the adult day health program to seek and consent to necessary medical treatment, including transportation to a hospital by emergency services. Reasonable attempts will be made to contact the emergency contact prior to or at the time of transport when feasible.

I authorize emergency transport: Yes No

Consent for Services & Release of Information

I authorize enrollment in adult day health services, including nursing oversight, personal care assistance, therapeutic activities, health monitoring, and social support as described in the program intake materials provided. I understand the nature and purpose of these services, the reasonably foreseeable benefits, and potential risks associated with participation.

I authorize the adult day health program and its staff to communicate with my primary care provider, specialists, pharmacies, hospitals, emergency services, and my designated emergency contact for purposes of coordinating care, obtaining medical orders, and sharing necessary health information. This authorization includes release of medical records as needed to facilitate treatment and billing.

This authorization is valid until: . I understand I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance upon it.

HIPAA / Privacy Acknowledgment: I acknowledge that I have received or been offered the program's Notice of Privacy Practices describing how my health information may be used and disclosed. I understand my rights regarding protected health information and consent to routine disclosures for treatment, payment, and healthcare operations.

Transportation & Activity Participation

I consent to transport for program activities or appointments by program staff or contracted providers under appropriate safety measures.

I understand participation in program activities is voluntary and that I may refuse any specific activity or service. Staff will make reasonable accommodations for my safety and dignity while participating.

Advance Directives & Special Instructions

Advance directive (living will, durable power of attorney for healthcare) on file: Yes No

Acknowledgment & Certification

By signing below, I certify that the information provided on this form is true and complete to the best of my knowledge. I consent to the delivery of adult day health services as described above and authorize disclosure of necessary health information to coordinate care and billing. I understand that I may withdraw consent at any time in writing, except where action has already been taken in reliance on this consent.

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