Building Healthy Communities through Medical-Religious Partnerships

IV. APPENDIXES

Bb iv appendixes This page intentionally left blank Appendix A Congregational Survey We are interested in organizing some programs on health-related topics that are of interest to members of the congregation. You can help us plan for these programs by completing this brief survey. Please place a check by the topics you would be interested in learning more about. Adolescent health issues Alcohol abuse Anxiety disorders Arthritis Assistive devices Automated external defibrillators (AED) Cancer Cardiopulmonary resuscitation (CPR) Dementia/Alzheimer’s disease Depression Diabetes Digestive disorders Do not resuscitate (DNR) orders Exercise and health Eye diseases/vision problems Heart disease Hospice care Hypertension Living wills/advance directives Long-term care arrangements 206 appendixes Medications—prescription Medications—nonprescription Men’s health issues Mobility equipment Nutrition and health Orthopedic problems Pain management Palliative care Prevention of falls and accidents Respiratory disorders Respite care programs Sleep disorders Smoking cessation programs Stress management Support groups Vaccinations (influenza and pneumonia) Weight reduction programs and methods Women’s health issues Suggestions Appendix B Program Evaluation Form We would greatly appreciate your taking the time to complete this brief questionnaire . By doing so, you can help us plan for future programs. I found this program to be informative and helpful. Strongly agree Agree Disagree Strongly disagree Based on what I learned in this program, I feel better equipped to handle health matters. Strongly agree Agree Disagree Strongly disagree What could have been done to make this program better? What topic(s) would you like covered in future programs? 208 appendixes Other suggestions or comments? Appendix C Patient Check Sheet Name Date How do you rate your health? excellent good fair poor Have you been hospitalized in the last year? no 1 time 2–3 times more than 3 times Have you used an emergency room in the past year? yes no Vaccination status (date last received): Influenza Pneumococcal Tetanus Symptom review (check if a problem): Visual difficulties Hearing difficulties Forgetfulness Sleeping problems Depression or loss of interest in usual activities Other types of emotional distress Urinary incontinence/leakage Fecal (bowel movement) incontinence 210 appendixes Have you experienced any of the following events in the last year? (circle answers and describe if yes) Yes No Death of a spouse Yes No Death of other close family member Yes No Marriage or new companion Yes No Change in financial status Yes No Change in living situation Yes No Loss of long-time pet Yes No Divorce or separation Living situation: House Apartment Other Alone With other person(s) List important aspects of your living situation Difficulties with basic and instrumental activities of daily living: Walking or moving Using the toilet Managing medications Bathing Personal grooming Managing money Shopping Dressing Preparing meals Housekeeping Transferring (into and out of bed or chair) Using the telephone Eating Appendix D Patient Information Sheet Date Name Phone Surrogate decision-maker (and relationship) Phone Advocate Advance directives Allergies Pharmacy Phone Current Prescribed Medications Drug Dosage and Frequency Current Nonprescription Medications and Nutritional Supplements 212 appendixes Patient needs assistance with these basic and instrumental activities of daily living: Incontinence problems: Bladder? Yes No Bowel? Yes No (circle answer) Other concerns: Prioritized problem list: 1. 2. 3. 4. 5. Appendix E Summary Form for Physician Visit Physician’s assessment of overall health status: Same Improved Worsened New problems identified by physician: New medications or changes in previous therapy: Other physicians who need to be seen for consultation: Name Phone Address Date of appointment Time of appointment 214 appendixes Name Phone Address Date of appointment Time of appointment Tests that need to be done before the next visit: Name of test Location Phone Date of appointment Time of appointment Name of test Location Phone Date of appointment Time of appointment Other instructions: Next appointment (date and time): Reviewed by (physician’s initials): Appendix F Medication Record Name Date Completed by Primary physician’s name Physician’s telephone number Pill Size Time Taken Compliance (e.g., 5 mg, Color and (e.g., 8 a.m., (e.g., always, Prescribed Medication What Is It For? 1 capsule) Shape...