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MEDTEX HOME CARE - Intake Form - Georgia Pediatric Program
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Patient's Name
*
Your answer
Date of Birth
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MM
/
DD
/
YYYY
Address
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Your answer
Phone Number
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Your answer
Email address
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Your answer
Emergency Phone Number
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Your answer
Responsible Party's Name
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Your answer
Relationship to Patient
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Parent/Guardian
Other
Description of Services Desired
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Personal Care
Nursing Care
Primary Diagnosis
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Your answer
Functional Limitations
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Your answer
Child's Weight
*
Your answer
Type of Medicaid and Medicaid Number
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Your answer
Does the patient have another insurance besides Medicaid?
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Your answer
Doctors' Names, Addresses, and Phone Numbers
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Your answer
Medications
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Your answer
Is the patient in school?
If so, is there a nurse with the patient in school?
Is there an IEP?
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Your answer
Does the patient receive any other services?
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Your answer
Nutritional Needs
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Your answer
Diet Information
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Your answer
Special Treatments
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Your answer
Special Equipment
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Your answer
Allergies
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Your answer
Behaviors that may interfere with delivering services
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Your answer
Goals and objectives
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Your answer
Days of the week and times desired for services
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Your answer
Initial Date of Contact
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Your answer
Date of Referral and Source of Referral
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Your answer
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