Vinland Medical Screening Form

Client Name / Date of Birth

Date this form is filled out

Gender Identity: Male/Female/Non-Binary/Other:

Last date of use

Substances used

Person helping client fill out this form and Contact#

Phone

Email

1) a. Do you require 24-hour skilled nursing care?

1) b. Self-preservation skills: In an emergency (fire, gas leak), are you able to take proper action
(get out of the building)?

2) What medications and doses are you currently taking?

2) a ) i. Do you take any controlled substances/narcotics?

2) a ) ii.Who manages this?

2) b. What medications and doses are you supposed to be taking?

3. Do you have any allergies to medications, foods, etc?

4. What are your current medical diagnoses?

5. What chronic medical conditions do you have?

6. What are your mental health diagnoses?

7. Do you have any infections which could spread to others?

7) a. Any history of MRSA?

7) a ) i. Any active lesions, sores or bites?

7) b. Past history or current symptoms of TB?

7) b ) i. When and where was your last TB test done? What were the results?

7) b ) ii. Night sweats, cough, bloody sputum, fevers, unintended weight loss?

8. Any history of seizures?

9. Have you, or any of your close contacts* traveled outside of the country/state within the past couple
months? (*A close contact is defined by someone you live with or are in close contact with every day)

10. Do you have symptoms of a cough or fever?

11. Are you diabetic?

11) a. Insulin?

11) b. Oral medications?

11) c. Who helps you manage your diabetes?

12. Have you had a blood clot (DVT-Deep Vein Thrombosis, PE-Pulmonary Embolism)?

12) a. Are you currently on a blood thinner?

12) b. If taking Coumadin/Warfarin, who manages this?