The Brain Injury Rehabilitation Center Brain Injury Rehabilitation Services for the Whole Person

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1 The Brain Injury Rehabilitation Center Brain Injury Rehabilitation Services for the Whole Person

2 The Brain Injury Rehabilitation Center Application for Brain Injury Rehabilitation INF-2 Return information to: Ron Sasso, Director (605) The Brain Injury Rehabilitation Center 803 Soo San Drive Rapid City, SD GENERAL INFORMATION Legal Name (First) (Middle) (Last) Current Address: Phone # City State Zip Social Security Number: Date of Birth Sex Height Weight Marital Status: Single Married Separated Divorced Widowed LEGAL INFORMATION Is applicant a minor or been declared incompetent by a judge? Yes Legal Guardian: (Please attach copies of guardianship papers if applicable) Name: Current Address: Phone # City State ZIP Does Applicant have any prior legal convictions? Yes If yes, felony or misdemeanor? Most serious charges: MEDICAL List known allergies: Any medical problems prior to injury? Describe: Cause of brain injury: Date of brain injury: Age at injury: Dates of other head injuries and cause of injury: Does the applicant have seizures? Yes Type of Seizures:

3 Other Medical Concerns: Does applicant currently operate a motor vehicle? Yes Did applicant consume alcohol and/or non-prescription drugs prior to injury? Yes If so, what type and how often? CURRENT PRESCRIPTION MEDICATIONS Name of Medication Dosage and Frequency Prescribing Doctor Current Primary Physician: Date of last exam Address Phone # City ST ZIP FAMILY Name of Spouse Married how long? Children of Applicant: NAME AGE GENDER EDUCATION Highest Grade Completed: H.S. Diploma or GED: Was applicant in any special classes? Yes Other Degrees or Diplomas Earned: Best Subjects: Worst Subjects: Colleges/Trade Schools Attended:

4 Name of Most Recent or Current Employer: VOCATIONAL Dates of Employment: Address: Job Responsibilities: Reason for Leaving (if applicable): Wage: Most significant former Employment: Dates of Employment: Address: Job Responsibilities: Reason for Leaving: Wage: MILITARY SERVICES Have you served in any of the US military branches? Branch Yes Are you eligible for VA benefits? Yes FINANCIAL INFORMATION Have you applied for Social Security Benefits? Yes Result: Social Security Amount: Other Source of Income: SSI Amount: Amount: INSURANCE INFORMATION Medicaid #: Medicare #: Private Health Insurance: Yes (If Yes, please list below): (Company) (Address) (Policy Number)

5 Circle all the words below that describe the applicant BEFORE THE INJURY Other: Happy Depressed Impulsive Self-controlled Meticulous Neglectful Strong-Willed Apathetic Out-going Shy Cooperative Uncooperative Anxious Calm Sexually Aggressive Physically Aggressive Patient Impatient PERSONALITY Circle all the words below that describe the applicant SINCE THE INJURY Other: Happy Depressed Impulsive Self-controlled Meticulous Neglectful Strong-Willed Apathetic Out-going Shy Cooperative Uncooperative Anxious Calm Sexually Aggressive Physically Aggressive Patient Impatient Comments: What is most frustrating for the applicant to deal with since the injury? Applicant s desired outcome of treatment? Applicant s life goals?

6 IN CASE OF EMERGENCY Name Address Home Phone Work Phone City ST ZIP Name Address Home Phone Work Phone City ST ZIP NOTE: Please attach any medical information that you may have regarding your brain injury, particularly any neuropsychological evaluations, discharge summaries, or any other evaluations.

7 MED-3 The Brain Injury Rehabilitation Center INITIAL PHYSICAL EXAMINATION This form must be completed and signed by a licensed physician. Applicant Name: Sex DOB HAS THE PATIENT SUFFERED FROM ANY OF THE FOLLOWING: (PLACE X) Frequent headaches Hemorrhoids Burning on urination Difficulty with vision Fainting Blood in urine Difficulty with hearing Chest pain Excessive fatigue Asthma/hay fever Unusual weight loss/gain Shortness of breath Persistent cough Cough producing blood Unusual irritability Swollen ankles Loss of appetite Frequent indigestion Varicose veins Diarrhea/constipation Ulcers Hernia (Rupture) Accidents (Describe) Fractures (Describe) Other (Describe) Operations (Describe) Seizures Describe: If seizures, are seizures controlled? Yes Frequency Type PHYSICAL EXAMINATION: PLEASE CHECK ITEMS THAT WERE EXAMINED AND FOUND TO BE NORMAL. DESCRIBE ABNORMAL FINDINGS. Height (w/o shoes) Weight Temperature F Blood Pressure Pulse Respirations Eyes: R L se: Throat: Ears: R L Mouth: Neck: Lungs: R L Heart: Abdomen: Pelvic: Prostrate: Feet: Lab: CBC CCB Pre-Admission TB results: Date: PAP Pre-Admission HEP B Date: Thyroid screening results: UA Blood Sugar Orthopedic Impairment: (Describe)

8 Physical Activities: rmal Limited (Explain) Exercise Program: Walking or Treadmill Times per week Minutes Work and/or activities to be avoided: Current Diet: Changes: Allergies: CURRENT PRESCRIPTION MEDICATIONS Name of Medication Dosage and Frequency Prescribing Doctor May patient self-administer medications with supervision? Yes WHICH OF THESE OVER THE COUNTER MEDICATIONS MAY THE CLIENT TAKE PRN PER PACKAGE INSTRUCTIONS? Yes Acetaminophen Yes Cepastat lozenges Yes Sun Screen Yes Ibuprofen Yes Bacitracin Oint Yes Midol Yes Pepto-Bismol Yes Hydrocortisone Cr Yes M.O.M. Yes Maalox Yes Debrox Eardrops Yes Sudafed Yes Tums Yes Calamine lotion Yes Benadryl Yes Kaopectate Yes Tinactin cr/pwdr Yes Cough Drops Yes Robitussin Syrup Does this individual have a Brain Injury? Yes Comment: Is this individual medically stable? Yes Comment: Does this individual need daily nursing services? Yes Comment: Is the disability likely to continue indefinitely? Yes Comment: Physician Signature Date Print Name Phone # Address: City ST ZIP

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