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H.E.L.P. for Diabetes 11700 W. 2nd Place Suite 310 Medical Plaza 2 Lakewood, CO 80228 720-321-8300 Diabetes Self Assessment List Medication and food Allergies: Name __________________________ Date: _______________________ To be completed by Diabetes Education staff: Ht _____ Wt _____ BMI ____ BP ________ Please complete this form before attending your first diabetes education class. You may add any comments you would like us to know about. In each question, check all answers that apply. 1. Do you have any situations that may make it harder for you to care for your diabetes? Physical disability Poor vision Cultural differences ________________ Language Poor hearing I have difficulty understanding I have financial problems I am not motivated I have emotional problems I don’t read very well I am not ready to learn about diabetes None Comments: _________________________ 2. Primary language preferred for education: __________________________ 3. When you are learning new information, what is your preferred method of learning? (Check all that apply) I prefer to read about it I like to discuss it with others I like demonstrations I like to hear a lecture on the subject I prefer to watch a video No preference Other: ___________________________ 4. Current diabetes treatment plan New diagnosis Type 1 Type 2 Pre diabetes Gestational Diabetes Treated with Oral medication Treated with injectable medication but not insulin Treated with insulin I have complications related to diabetes I have a change in treatment for diabetes Comments: _________________________ 5. What year were you diagnosed with diabetes __________________ 6. What is your Ethnic background? White/Caucasian Native American/American Indian Alaska native Asian African American/Black Hispanic/Latino Middle Eastern Other: __________________ 7. How are you currently feeling about having diabetes? I’m pretty angry about it I’d rather not think about it I’m afraid of what diabetes will do to me I’m sad my health has changed It’s hard to get it under control. I’m doing OK and will be able to manage my diabetes I’m not coping with the changes I have to make Comments: ____________________________ 8. I currently have the following symptoms related to diabetes: Blurred vision Fatigue High blood sugar (hyperglycemia) Low blood sugar (hypoglycemia Nausea and vomiting Thirst Hunger Frequent urination Slow healing wounds Sweating Weight gain Weight loss None Comments: ________________________________ 9. Are you having pain that affects your ability to manage your diabetes? Yes No Comments: __________________________ 10. On a scale of 1-10, with 10 being the worst pain, how would you rate your pain? 1 2 3 4 5 6 7 8 9 10 11. Who do you see about your pain? ____________________________________ 12. Do you have other risk factors that may affect your health? None Age (over 40) High blood sugars for a long time High cholesterol or triglycerides Family history of diabetes Gestational diabetes or a baby over 9 pounds High blood pressure (hypertension) History of impaired glucose tolerance Obesity Sedentary lifestyle Smoking Comments: __________________________ 13. Do you have or have you had any of the following conditions? Heart disease Eye problems Kidney problems Retinopathy Nerve damage) Sexual difficulties Hypoglycemia unawareness Foot problems Sores that won’t heal Dental disease Depression None Comments: _________________________________ 14. For women only: I use birth control type-_____________ I am not using birth control I am infertile I am post menopausal I plan to become pregnant I am pregnant I am sexually active I have had a tubal ligation or hysterectomy Physician has discussed risk of pregnancy Comment: ___________________________ 22. What are your typical work hours? Days Nights Evenings Comment: __________________________ 15. Past medical/surgical history _______________________________ 24. Do you have a dental exam every 6 months? Yes No 16. Other current medical conditions for which you are being treated: ____________________________________ ____________________________________ ____________________________________ ____________________________________ 17. Current home status: I live alone I live with my spouse I live with significant other specify _________________ I am in an unsafe relationship. Other: ______________________ 18. Primary diabetes support person is Name ________________________ Relationship____________________ 19. Number of people in the household _______________________ 20. Highest level of education ________________________ 21. Occupation ____________________________ 23. Do you have a dilated eye exam every year? Yes No Date of last exam: _________________________ 25. Do you use alcohol? Yes No How much do you drink? Drinks per week ____________________ Usual alcoholic beverage______________ 26. Do you use tobacco? Yes No How much? Packs per day ____________ Chewing Tobacco packs per day _________ 27. Do you use street drugs? Yes No How often? ______________________ What do you use? _________________ Comment: __________________________ 28. Have you had a foot exam within the past year? Yes No Don’t know 29. Have you had a flu shot in the past year? Yes No Don’t know 30. Have you had a pneumonia shot in the past 5 years? Yes No Don’t know 31. Has your weight changed? Yes No Gained or lost? And why? ________________________ 32. What is your usual eating behavior? I count carbohydrates I try to eat low fat I avoid sweets I eat anything I want I try to control portions Comment: _________________ 33. How is your appetite? Good Fair Poor Comment:___________________ 34. Where are most of your meals prepared? Home Home and away Most are away 35. How would you describe your monthly food budget? I have enough money for food I do not have enough money for food I would like information about food assistance 36. In the past month, have you had a blood sugar less than 70mg/dl? Yes No Don’t know When does this happen and why? ____________________________________ ____________________________________ 37. What are your symptoms of low blood sugar? None Dizzy Sweaty Headache Hunger Loss of consciousness Seizure Shaky 38. How do you treat your low blood sugar? ____________________________________ ____________________________________ 39. Do you wear Diabetes Medical identification? Yes No 40. Do you have a Glucagon injection kit on hand at home? Yes No Don’t know 41. Do you check urine ketones at home? Yes No Not applicable 42. Have you been in the hospital recently for high or low blood sugar? Yes No Date and which hospital? ________________________________ 43. Which topics do you need to learn more in order to manage your diabetes better? (Check all that apply) Physical activity Blood sugar testing Reducing other risk factors Nutrition and diet Learning to solve problems related to diabetes Understanding what diabetes is Taking medications properly Emotional adjustment 44. Describe your daily activity I am involved in a regular exercise program I am able to do the usual activities involved with daily living I do not exercise due to physical limitations/problems 45. What type of exercise do you do, how often and for how long each time? __________________________________ 46. How often do you check your blood sugar? Once a day Twice a day Three times a day Four times a day 2 hours after meals At 3 AM I never check my blood sugar Other: ___________________________ 47. What is the type of meter that you have? (exact name) ________________________ 48. In the past week, what is your range of blood sugar? In the AM? ________________ At Noon? ___________________ At Dinner? _______________ At Bedtime?________________ Other: _________________________ 49. What is your personal blood sugar goal? __________________________________ 50. List all of your current medications Or attach a list: Name dose Times that you take it ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ 51. How often so you miss taking your diabetes medicine? ____________________________________ Why do you miss? ____________________________________ 52. Do you have any problems with the site of your injections? Yes No Comments: ____________________________ 52. How do you store your unopened bottle or pen of injectable medication? ___________________________ How do you store the bottle or pen you are currently using? __________________________ 53. Is there anything else you would like us to know about you or your health? ____________________________________ ____________________________________ ____________________________________ Ebola Virus Disease (EVD) Screening Questionnaire 10/20/14 QUESTIONNAIRE Form Completed by: Patient Patient Name Bar Code Label Page 1 of 1 Caregiver Other______________________________________ To ensure the safety of patients, volunteers, visitors and staff, all patients presenting to the Emergency Department or any admitting area will be asked the following questions. Please select an answer for each question: Yes No 1. Fever/temperature of greater than or equal to 38 degrees Celsius or 100.4 degrees Fahrenheit. 2. Travel to West African countries of Guinea, Liberia or Sierra Leone within last 21 days. 3. Any contact with someone who is known to have been diagnosed with Ebola or known to have recently traveled to one of the areas above in the last 21 days. Date:_________________ Time:_____________ Signature of Person Completing Form:___________________________________________________ Patient Label Page 1 of 1 Outpatient Fall Risk Tool CHADM-023 rev. 02/13 FALLRISKQ Date: _______________ Time: _______________ Form Completed by: Patient Caregiver Other: __________________________________________ Are You At Risk for A Fall? To ensure your safety at today’s visit, please answer the following questions. Please select an answer for each question: 1. Have you had a fall in the last 12 months? Yes 2. Are you here because of a recent fall? 3. Do you have difficulty with walking or balance? 4. Do you have a fear of a fall? 5. Do you take medications that may make you dizzy or unsteady? 6. Would you like extra help today to avoid falling? No If the answers to the questions above are NO, no further interventions are needed. If you answer “Yes” to ANY question you are at risk for falling. For internal use only If patient is at risk for falling, see precautionary measures below: For use within the registration area: Use a wheelchair for transport (if applicable) Instruct patient/family to request assistance with mobility Identify fall risk patient using a yellow wristband/yellow sticker patient declined; initial ___________ For use within the treatment area: i. Equipment safety: i.e. lock all moveable transfer equipment, utilize side rails ii. Orient patient to surroundings and environment iii. Instruct patient/family to request assistance with mobility iv. Assist with transfers and ambulation including wheelchair for transport v. Identify fall risk patient using a yellow wristband/yellow sticker on chart (per SOP) Hospital Service Agreement CHADM-001 rev. 05/13 Page 1 of 2 Patient Barcode Label Must be placed in this space Hospital service agreement 1. Consent for health care services. I voluntarily consent to and authorize the rendering of health care services, including routine hospital services, diagnostic procedures, intravenous therapy, medications, injections, laboratory services, and other services or procedures, including the use or potential use of restraint, which my attending physician or others holding clinical privileges consider necessary. I understand that health care services may be rendered by students, interns or residents under supervision. I further understand that the practice of medicine is not an exact science and I acknowledge that no promises or guarantees have been made to me regarding treatment or services rendered in this health care facility. I understand that my rights and responsibilities with regard to my care are described in more detail on the Patient Bill of Rights document. 2. Independent practitioners. I understand that many of the professionals who provide care to me in the hospital are not employees or agents of the Hospital. These professionals may include my own physician, other physicians requested by my physician to participate in my care as well as emergency department physicians, radiologists, pathologists and anesthesiologists. As a result, I understand that these professionals will bill me for charges that are separate from those of the Hospital. I understand that, in some cases, these professionals may not be participating providers under my insurance plan. The Hospital recognizes that this can be both frustrating and costly because I may be responsible for out of network costs or other costs because the professional does not have a contract with my insurance plan. I understand it is my responsibility to verify whether professionals providing my care are participating providers under my insurance. 3. Medicare and/or Medicaid Certification. I certify that the information given by me in applying for payment under the Medicare and/or Medicaid programs is correct, and I authorize the release of all information needed to act on this request. I request that payment of authorized benefits be made to the Hospital on my behalf for the Hospital’s and physicians’ charges for which the Hospital is authorized to bill in connection with these health care services. 4. Retention of specimens. I authorize the Hospital to take, retain, preserve and use for scientific or teaching purposes, or dispose of at its convenience, all specimens, tissues, parts, or organs taken from my body during my hospitalization. 5. Financial Agreement. I understand that there is no guarantee of reimbursement or payment from any insurance company or other payor. I acknowledge full financial responsibility for, and agree to pay, all charges of the Hospital and of physicians rendering services not otherwise paid by my health insurance or other payor. Estimated patient responsibility is due at the time of service or following the medical screening exam. Any remaining charges are due and payable upon receipt of the bill. If I do not have insurance or I cannot pay my bill, I may qualify for financial assistance. I understand that I may be required to submit documentation to determine my eligibility for financial assistance. I understand the hospital may request and use data from third parties such as credit reporting agencies in order to verify demographic data or evaluate financial options. If payment is not made within 90 days after receipt of the bill, a delinquent charge or interest at the maximum legal rate may be added. I agree to pay all reasonable legal expenses necessary for the collection of any debt. I acknowledge and understand that any refund that I may be owed will first be applied to any outstanding balance, and the remainder will be forwarded to the address on file with the Hospital. I consent to be contacted by regular mail, by e-mail or by telephone (including a cell phone number) regarding any matter related to my account by the Hospital or any entity to which the Hospital assigns my account. I also consent to the use of any updated or additional contact information that I may provide by the Hospital or any entity to which the Hospital assigns my account, as well as to the use of technology including auto-dialing and or prerecorded messages in contacting me. Hospital Service Agreement CHADM-001 rev. 05/13 Page 2 of 2 Patient Barcode Label Must be placed in this space 6. Preauthorization requirements. I understand that it is my sole responsibility to obtain all pre-authorizations and to comply with all requirements of any insurance or medical/hospital coverage plan upon which I am relying for coverage of the Hospital’s and physicians’ charges. 7. Assignment for direct payment. I authorize and direct that payment of any insurance or health care benefits otherwise payable to me for health care services or goods be made directly to the Hospital and my physicians, to include any hospital-based radiologists, pathologists, anesthesiologists and emergency department physicians. I understand that I am financially responsible to the Hospital or my physicians for charges not covered or paid pursuant to this authorization. 8. Personal Valuables. The Hospital maintains a safe for the safekeeping of any money or valuables. I understand that the Hospital does not assume responsibility for the loss, damage, or disposal of my personal property or money including jewelry, clothing, dentures, eyeglasses, contact lenses, hearing aids, prosthetic devices, or any other item unless such money or property is deposited with the Hospital. I take full responsibility for any money or property retained in my possession/room or brought to me while I am a patient at the Hospital. 9. Acknowledgement of Notice of Privacy Practices. I acknowledge that Centura Health has offered me a copy of its Notice of Privacy Practices. I understand that the Notice of Privacy Practices is also electronically available on Centura Health’s web-site. I understand this acknowledgement in no way affects the care I receive at the Hospital. By checking one of the boxes below, I acknowledge: I accepted a copy of the Notice of Privacy Practices I declined a copy of the Notice of Privacy Practices Facility Representative Comments:_______________________________________________________________________ 10.Acknowledgement of Patient rights and responsibilities. I acknowledge that I understand that the Patient Bill of Rights document includes information on my rights and responsibilities as a patient, as well as information about how to bring concerns or grievances to the appropriate parties. I agree to accept the consequences if I disregard my rights and responsibilities. I acknowledge I have read this form and understand its contents and have received a copy hereof. I further acknowledge that I am the patient, or person duly authorized either by the patient or otherwise, to sign this agreement, consent to, and accept its terms. _________________________________________________________ _________________________________________________________ Signature of patient or legally responsible person Name (Print) _________________________________________________________ Date __________________ Time _______________________ relationship/reason why patient is unable to sign address of patient: _________________________________________________________________________________________ Patient Label Page 1 of 1 Important Health Care Decisions #0004NS rev. 05/10 ADMADVDIRQUEST Important Health Care Decisions St. Anthony Hospitals (and Colorado Law) knows that every adult has the right to make decisions about their own health care. We hope that you have talked with your family, friends, significant others, and doctor(s) about your wishes. You have the right to consent to (accept) or refuse any medical care and treatment, unless care is ordered by a court. In an emergency, your consent to resuscitation, medical care and treatment is assumed. The three Advance Directives you may sign are listed below with a brief explanation of each: 1. Medical Durable Power of Attorney: A document you sign naming someone to make your health care decisions. The person you name is called “your agent”. Your Medical Durable Power of Attorney can become effective immediately or when you become unable to make your own medical decisions. 2. Living Will: A document you sign telling your doctor NOT to use artificial life support methods if you become terminally ill. This means an incurable or hopeless condition where life-sustaining procedures will only postpone the moment of death. 3. Colorado Cardiopulmonary Resuscitation (CPR) Directive: A directive signed by you, or your agent or proxy and your doctor. This directive means that you do not want to be resuscitated. If you do not have a “CPR” Directive your consent to cardiopulmonary resuscitation will be assumed. Other Substitute Decision Makers: 1. Guardian: A person appointed by a court to help with the personal affairs of an individual who is unable to make his or her own decisions. 2. Medical Proxy: Under Colorado law, family members and close friends have the right to choose a substitute decision maker (Proxy) for a patient who does not have an Advance Directive or guardian and if a doctor or a judge determines that you are unable to make medical decisions. 3. Organ Donation: Any Living Will, Medical Durable Power of Attorney and CPR Directive may include a written statement about a decision regarding organ and tissue donation. If you are registered as an organ donor, your family is not required to give permission regarding your wishes for organ donation. You should notify your family of your decision to be an organ donor. Please understand that you are not required to have an Advance Directive in order to receive care and treatment, or for admission to a hospital. If you have a written document about medical treatment be sure to tell your doctor or nurse. Please tell the appropriate people where you keep this document. Your doctor should have a copy of this document in his/her files for you as well. If you do not have your written document with you, please tell the doctor or nurse of your wishes about your Advance Directives and ask your family to bring a copy to the hospital to have it placed in your record. Again, please talk with your family, friends, significant others, and doctor(s) about your wishes regarding health care decisions. In addition, please understand each time you are hospitalized this issue will need to be discussed in order to assure your wishes are made clear. Does the patient have an Advance Directive? Yes If Yes, which type: Colorado CPR Directive Living Will No Medical Durable Power of Attorney, Name: ______________________ Phone #: ______________ Copy attached to medical record: Yes No Copy requested from: _____________________________ (name) Patient stated copy provided on previous admission If No: Patient given Advance Directives pamphlet Copy at home Patient declined Pamphlet Date: ____________________ Time: ____________________ PATIENT BARCODE LABEL MUST BE PLACED IN THIS SPACE Patient Bill of Rights #CHADM-019 rev. 06/11 Page 1 of 2 PATIENT BILL Patient Rights: Centura Health Hospitals support the rights of all patients across the lifespan including geriatric, adult, adolescent, pediatric, infant and neonatal populations. These rights may be exercised through the patient individually or through their surrogate decision maker/legal representative. You have the right to. . . 1. Be informed of your patient rights in advance of receiving or discontinuing care when possible. 2. Have impartial access to care and visitation. No one is denied access to treatment or visitation because of disability, national origin, culture, age, color, race, religion, gender identity, sexual orientation. No one is denied examination or treatment of an emergency medical condition because of their source of payment. 3. Give informed consent for all treatment and procedures with an explanation in layman terms of: • Recommended treatment or procedure. • Risks and benefits of the treatment or procedure. • Likelihood of success, serious side effects, and risks including death. • Alternatives and consequences if treatment is declined. • Explanation of the recovery period. • Whether physicians or qualified medical providers other than the operating physician will be performing important parts of the surgery or administer the anesthesia. 4. Participate in all areas of your care plan, treatment, care decisions, and discharge plan. 5. Have appropriate assessment and management of your pain. 6. Be informed of your health status/prognosis. 7. Be treated with respect and dignity. 8. Personal privacy, comfort and security to the extent possible during your stay. 9. Be free from restraints or seclusion imposed as a means of coercion, discipline, convenience or retaliation by staff. OF RIGHTS 10. Confidentiality of all communication and clinical records related to your care. Receive a copy of our Notice of Privacy Practices to inform you how your personal medical information can be used and disclosed and your rights related to your medical information. 11. Have access to telephone calls, mail, etc. Any restrictions to access will be discussed with you, and you will be involved in the decision when possible. 12. Have the right to choose a “visitor” who may visit you, including but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and your right to withdraw or deny such choice at any time. You also have the right to an identified “support person” who can make visitation decisions should you become incapacitated. 13. Have access to interpreter services at no cost to you or your companion when you do not speak or understand the language, as well as communication aides, at no cost, for the deaf, blind, speech impaired, etc., as appropriate. 14. Have access to pastoral/spiritual care. 15. Receive care in a safe setting. 16. Be free from all forms of abuse or harassment. 17. Have access to protective services (e.g., guardianship, advocacy services, and child/ adult protective services). 18. Request medically necessary and appropriate care and treatment. 19. Refuse any drug, test, procedure, or treatment and be informed of the medical consequences of such a decision. 20. Consent to or refuse to participate in teaching programs, research, experimental programs, and/or clinical trials. 21. Receive information about advance directives. Set up or provide Advance Directives and have them followed. Designate a surrogate decision-maker (legal representative) as permitted by law and as needed. 22. Participate in decision-making regarding ethical issues, personal values or beliefs. PATIENT BARCODE LABEL MUST BE PLACED IN THIS SPACE Patient Bill of Rights #CHADM-019 rev. 06/11 Page 2 of 2 23. Have a family member or representative of your choice and your physician promptly notified of your admission to the hospital. The Office for Civil Rights Department of Health and Human Services 999 18th Street, South Terrace, Suite 417 Denver, Colorado 80202 Telephone: 303-844-2024 TDD 303-844-3439 Fax: 303-844-2025 24. Know the names, professional status and experience of your caregivers. 25. Have access to your clinical records within a reasonable timeframe. c. If after speaking with the hospital or system representative your complaint remains unresolved, you may contact The Joint Commission: 26. Be examined, treated, and if necessary, transferred to another facility if you have an emergency medical condition or are in labor, regardless of your ability to pay. The Joint Commission Division of Accreditation Operations, Office of Quality Monitoring One Renaissance Boulevard Oakbrook Terrace, IL 60181 Telephone: 1-800-994-6610 E-Mail: [email protected]. Fax: Office of Quality Monitoring (630)792-5636. 27. Request and receive, prior to the initiation of nonemergent care or treatment, the charges (or estimate of charges) for routine, usual, and customary services and any co-payment, deductible, or non-covered charges, as well as the facility’s general billing procedures including receipt and explanation of an itemized bill. This right is honored regardless of the source(s) of payment. 28. Be informed of the hospital’s complaint and grievance procedure and whom to contact to file a concern, complaint or grievance. Note: If you have financial issues or questions, please contact Centura Consumer Operations at (303) 715-7000. Toll free: 888-269-7001 a. Our priority is for you to have an exceptional patient experience. If your concerns are not being resolved with your immediate care giver or the department manager, please call the patient representative; or the hospital operator by dialing “0” and asking for Patient Representative or RN Administrative Manager b. You may also contact The Health Facilities Division of the Colorado Department of Public Health and Environment and the Office of Civil Rights directly regardless of whether you first used the hospital’s complaint and grievance process. The Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80222-1530 Telephone: (303) 692-2827 d. You also have the right to file a complaint with the Colorado Board of Medical Examiners, the State Board of Dental Examiners and the Colorado Podiatry Board if you have concerns with your physician, dental or podiatric patient care services, excluding fee disputes. Patient Responsibilities: You have the responsibility to . . . 1. Ask questions and promptly voice concerns. 2. Give full and accurate information as it relates to your health, including medication. 3. Report changes in your condition or symptoms, including pain, and request assistance of a member of the health care team. 4. Participate in the planning of your care, including discharge planning. 5. Follow your recommended treatment plan. 6. Be considerate of other patients and staff. 7. Secure your valuables. 8. Follow facility rules and regulations. 9. Respect property that belongs to the facility or others. 10. Understand and honor financial obligations related to your care, including understanding your own insurance coverage. Signature: ________________________________________________ Date: ___________________ Time: ________________
