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Standard Tabular Medical Face Sheet

This face sheet is used to document key personal and medical information for an individual. It includes their name, contact details, date of birth, physicians, medical history, medications, allergies, activity level, safety measures, equipment needs, treatments, emergency contacts, care coordinator, and directives concerning medical interventions. The face sheet is meant to be updated over time to ensure accurate information is available for caregivers.

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Adrienn Krisztina Varga
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235 views2 pages

Standard Tabular Medical Face Sheet

This face sheet is used to document key personal and medical information for an individual. It includes their name, contact details, date of birth, physicians, medical history, medications, allergies, activity level, safety measures, equipment needs, treatments, emergency contacts, care coordinator, and directives concerning medical interventions. The face sheet is meant to be updated over time to ensure accurate information is available for caregivers.

Uploaded by

Adrienn Krisztina Varga
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Face Sheet

1. Individual Name: 2. Phone: 3. Date of Birth Age: 4. Medicaid #:

5. Individual Address: 6. Principal Diagnosis: 7. Physicians: (include name and phone number)

8. Pertinent Past and Present Medical 9. Activity Level: 10. Safety Measures: 11. Equipment:
History (include: surgeries, hospitalizations,
etc.)

Food Allergies:

Diet:

12. Treatment Record: 13. Family/Other Back Up Persons: (Include Names and Phone Numbers)

14. Service and Support Administrator: (Name and Phone number with extension)

15. Marital Status: Sex: Race:


16. Medications – List all medications that the Individual takes on the back of this form and update the list as needed.
17. DRUG ALLERGIES:

18. Code Status: Advance Directives: YES NO

Revised 9.7.07
Instructions for completing Face Sheet
Update Face Sheet following any change in condition, birthday, or addition of new diagnosis or medications .
Section 1: Write Individuals Name
Section 2: Individuals Phone Number
Section 3: Individuals Date of Birth and current age of the individual
Section 4: Individuals Medicaid Number
Section 5: Individuals Address
Section 6: Principal Diagnosis (List all known Diagnosis for the individual)
Section 7: List all Physician’s that provide care for the Individual
Section 8: List all known surgeries, hospitalizations (be as specific as you can). List any food allergies and the
diet ordered by physician.
Section 9: Activity Level – This level is things like: (up as tolerated, up in wheelchair for 2 hours in AM and
PM). These may be limitations as to what the Individual is able to do physically.
Section 10: Safety Measures – These are things that the Individual may need to remain safe, (Ex: seatbelt when
up in wheel chair, bed rails up when in bed, Emergency Response system within reach)
Section 11: Equipment – This is the type of equipment that is used by the Individual. (Ex: type of wheelchair,
hoyer lift, bedside commode, transfer bench or board, braces, supports, etc…)
Section 12: Treatment Record – List any skilled nursing services, therapy services
Section 13: List the individual’s here that may be utilized as a backu p in the event that you are another person
cannot work their scheduled shift.
Section 14: Put the name and phone number, with extension, of the Service and Support Administrator
Section 15: List the individual’s marital status, sex, and race.
Section 16: Medications – List all medications that the Individual takes on the back of this form and update the
list as needed. When a medication is discontinued, write the date out to the right side of it and put the
initials D/C for discontinued.
Section 17: List drug allergies
Section 18: List the code status. Circle whether the individual has executed Advance Directives concerning
their health care interventions during times of crisis.

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