Healthcare Clinical Modules

Healthcare Clinical Modules

Patient Name:    Medical Record #:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Clinical Modules (Select required modules)

Vital Signs & Initial Screening — documentation of height, weight, blood pressure, pulse, temperature and oxygen saturation.

Medication Reconciliation — list current medications, dosages, and recent changes.

Pain Assessment — numeric rating, location, quality, and impact on function.

Fall Risk Assessment — timed up-and-go, history of falls, mobility aids, home safety review.

Mental Health Screening (PHQ-9 / GAD-7) — assessment of mood, anxiety, and suicidality with appropriate safety plan if indicated.

Cognitive Assessment — brief cognitive tests to evaluate memory, attention, and orientation.

Functional Mobility Assessment — ADLs / IADLs, use of assistive devices, transfer ability.

Wound Assessment — staging, measurements, drainage, and treatment plan.

Allergy and Immunization Review — verify documented allergies and immunization status.

Substance Use Screening — alcohol and drug use history with brief intervention if indicated.

If additional modules are required, specify:

Consent for Assessment Modules and Release of Information

I authorize the clinical team to perform the selected clinical modules and to record and maintain the results in my medical record. I understand that the information obtained will be used by the treating team for diagnosis, treatment planning, coordination of care and, where necessary, for communication with other health care providers and authorized third parties.

I acknowledge that participation in assessments is voluntary. I have the right to refuse any individual module without affecting my access to care. I may revoke this authorization at any time by submitting a written request to the facility's medical records office; revocation will not apply to disclosures made in reliance on this authorization prior to receipt of the revocation.

By initialing below I specifically authorize exchange of assessment results among members of my care team and designated external providers as required for continuity of care. Initials:

Authorization expiration date (optional):

Medical History — Current Clinical Information

Tobacco Use: Yes No    Alcohol Use: Yes No

Authorization to Share Results

I authorize disclosure of my assessment results to the following persons or organizations for the purpose of care coordination:

I understand that information shared pursuant to this authorization may include behavioral health, substance use, HIV-related, or other sensitive information as necessary for treatment and care coordination unless I have specifically excluded such categories below.

Clinician Assessment / Use Only

Privacy Acknowledgment (HIPAA)

I acknowledge receipt of the facility's Notice of Privacy Practices and understand how my protected health information may be used and disclosed for purposes of treatment, payment, and health care operations. I understand my rights to request restrictions, inspect and obtain copies of my health information, and to request amendment of my record as provided by law.

I acknowledge: I have received or been offered a copy of the Notice of Privacy Practices.

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