VERDEZA | Admission Evaluation for Short term stays and Post op recovery

Verdeza enhances the lives of its residents and provides peace of mind for the whole family

Admission Evaluation for Short term Stays

In order to give the best quality care possible to the patient, we would appreciate to complete the following medical information.

Fields marked with * are required.

Personal information

First Name*(required)

Last Name:*(required)

Email:*(required)

Passport Number:

Date of Birth:*(required)

Nationality:*(required)

Marital Status:*(required)

Address:*(required)

Contact in case of emergency:*(required)

Relation:*(required)

Telephone 1:*(required)

Telephone 2:

Preferred Hospital in case of emergency:*(required)

Arrival Details (only for patients or guests coming from abroad)

Arrival Date:

Flight #:

Time:

Departure Date:

Flight #:

Time:

Personal Pathologic History

Arterial Hypertension
Diabetes Mellitus
Ischemic Cardiomiopathy
Cerebral Vascular Disease
Gastritis

Asthma/ COPD
Cognitive Impairment
Thyroid disease

Other medical condition(s):

Medication

NAME	DOSE

Add medication | Remove medication

Personal Non Pathologic History

Smoking Alcoholism

Medication Allergies:

FOOD ALLERGIES:

Tomato Shrimp Gluten Iodine

Other food allergies:

Surgery information or medical procedure (if applies)

Describe the Surgery:

Doctor / Telephone:

Hospital or clinic:

Date / Time:

Doctor's Recommendation:

Select your special needs:

Wheelchair Hospital Bed Raised toilet seat Shower Seat Recliner Seat Walker

Other special needs:

Diet information:

Does the patient have any cognitive impairment?

Cognitively healthy
Mild cognitive impairment
Mild dementia
Moderate dementia
Severe dementia

What is the functional status?

Total independence of instrumental activities of daily living
Partial dependence of instrumental activities of daily living
Independent of basic activities of daily living
Partial dependence of basic activities of daily living
Dependence of basic activities

Reservation details

Check in:

Check out:

Total of nights:

Extra person in the room (non patient) Yes No

Full Name:

Relationship:

Observations:

We appreciate any additional information that you consider is important for our community to help us determine what type of assistance you need during your short term or recovery stay.

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