Patient Intake Lawrence Medical

Sunrise Home Health

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Patient Intake Lawrence Medical

Sunrise Home Health

Patient Intake Settings

Records

Patients Staff

Patient Intake Settings

Records

Patients Staff

Patient Intake

Registration, medical histories and consent.

Start an intake

Part 1 · The patient

New patient Patient already on file

Patient

First name

Last name

Date of birth

Sex

Phone

Home address

Room (facilities)

Code status

Emergency contact

Emergency phone

Physician

Primary diagnosis

Allergies

Part 2 · Health history

Health conditions

High blood pressureHeart failureHeart diseaseDiabetesCOPD or asthmaStrokeKidney diseaseDementiaDepression or anxietyCancerArthritisSeizures

Other conditions

Past surgeries

Hospital stays in the last year

Medicines taken at home (name and dose)

Walking and moving

Diet

Lives with

Hearing, vision, speech

Smoking or vaping

Alcohol

Family members we may update

Part 3 · Insurance

Insurance or payer

Member number

Group number

Part 4 · Consent

I agree to receive care and services from this facility.I received the notice of privacy practices.Staff may take photos of wounds for my care record.Staff may share updates about my care with the family members named below.

Hand the screen to the patient or their representative to sign. You can also save now and sign later.

Name of the person signing

Relationship to the patient