Healthcare Safety Test

HEALTHCARE SAFETY TEST

This Healthcare Safety Test is a clinical safety screening and patient acknowledgement used to assess immediate safety risks, document current medical and medication information, confirm patient understanding of facility safety protocols, and obtain authorization for safe delivery of healthcare services. Completion of this form assists clinicians in identifying infection risk, fall risk, medication concerns, and other factors that may affect the plan of care.

Patient Information

Insurance Information

Medical History

Safety Screening — Symptoms and Exposure (Check all that apply)

Within the past 72 hours:

Fever or chills

New or worsening cough

Shortness of breath or difficulty breathing

Sore throat

New loss of taste or smell

Known exposure to someone with a communicable illness within last 14 days

If any boxes are checked, clinical staff will assess risk and may institute isolation, testing, or other precautions as required by facility policy.

Patient Safety Knowledge Assessment

Please indicate whether you Agree or Disagree with the following statements regarding safety practices while receiving care at this facility.

I will verify my identity using two identifiers (name and date of birth) before procedures.
I acknowledge and agree

I understand that I should inform staff before taking any home medications or supplements.
I acknowledge and agree

I will use call bell or request assistance when mobilizing if I am unsteady or at risk of falling.
I acknowledge and agree

I understand the facility implements hand hygiene and personal protective measures to reduce infection transmission.
I acknowledge and agree

Fall Risk Assessment

Please check any that apply:

History of falls within past 12 months

Uses cane, walker, or wheelchair for mobility

Unsteady gait or difficulty with transfers

If any fall risk items are checked, staff will document a personalized fall-prevention plan including supervision and assistive devices as needed.

Infection Control and Immunizations

Please indicate immunization status where known:

Influenza vaccine this season: Yes No

COVID-19 vaccine series complete: Yes No

Other relevant infection control notes:

Acknowledgement, Authorization, and Certification

By signing below I certify that the information I have provided on this Healthcare Safety Test is complete and accurate to the best of my knowledge. I understand that omission of material facts or failure to report symptoms may place me and others at risk. I authorize clinical staff to apply appropriate safety precautions, perform testing when indicated, and include this information in my medical record for continuity of care. I understand I may withdraw consent for non-emergency treatments at any time by informing clinical staff.

HIPAA and Privacy Acknowledgement: I acknowledge that I have been informed of my privacy rights and that my health information will be used and disclosed as necessary for treatment, payment, and healthcare operations. I consent to the release of relevant health information to providers involved in my care and to my designated emergency contact when required for my safety.

Warning: Knowingly providing false information or withholding information relevant to safety may result in delayed or denied services and may be documented in the medical record.

Sign Now