Healthcare Medical At Risk Form

Healthcare Medical At Risk Form

Patient Information

Patient Name:    Date of Birth:

Male    Female    Other / Non-binary

Emergency Contact

Insurance Information

Clinical Summary and Risk Assessment

The purpose of this form is to document conditions that place the patient at increased medical risk for adverse events during care, transport, procedures, or discharge. The clinical team will use this information to implement targeted precautions. Patient or legal representative must acknowledge understanding of identified risks and planned mitigations.

Cardiac instability (e.g., recent MI, arrhythmia)
Respiratory compromise (e.g., oxygen dependency, COPD)
On anticoagulation or bleeding risk
Active or high-risk infection isolation required
Significant mobility/fall risk
Cognitive impairment or delirium risk
Insulin-dependent diabetes or brittle glucose control
Other (describe below)

Medical History

Precautions and Care Plan

The clinical team will implement the following precautions and interventions to mitigate identified risks. These measures will be communicated to care teams involved in the patient's treatment.

Telemetry / cardiac monitoring
Oxygen supplementation / respiratory support available
Fall precautions / assist with transfers
Isolation / infection control measures
Medication reconciliation and bleeding risk review
Frequent glucose monitoring
Advanced life support readiness as indicated

Authorization and Acknowledgment

I acknowledge that I have been informed of the conditions that place me at increased medical risk. I understand the precautions and interventions recommended to reduce likelihood of adverse events. I authorize clinical staff to provide necessary treatment, emergency interventions, and to implement the precautions listed above. I understand that I have the right to ask questions, to refuse or withdraw consent for particular interventions to the extent permitted by law, and to designate a representative to act on my behalf.

I authorize the clinical team to disclose relevant portions of my medical record related to these risk factors and care plan to the following persons for coordination of care or emergency notification:

By signing below I certify that the information provided is true and complete to the best of my knowledge, that I have had an opportunity to discuss my risks and the care plan with a member of the clinical team, and that I understand the actions to take and who to contact in case of deterioration or emergency.

I certify the above statements.

Sign Now