<p> Physician Summary Form Patient Last name First name Date of birth Gender SSN</p><p>Diagnosis Diagnosis(es) Mental retardation Y___ N ___ Psychiatric diagnosis Y___ Developmental N___ disability </p><p>Treatments Medications taken List type and frequency list drugs, dose, route and frequency ______Ordered therapies ______By a licensed professional ______(OT, PT, ST, etc) ______</p><p>Recent vital signs Allergies Date: __ no known __ no known Height Continence Mental status T: allergies drug allergies Bowel Bladder __ Alert & oriented allergies list______P: ___ continent ___continent __Alert & disoriented R: ______Other Weight __ incontinent __ incontinent ______BP ______colostomy ___ catheter ______Additional comments /special needs Lab work______Date of last P.E. ______Date of last office ______visit ______</p><p>Recommend this patient for the following services Adult day health (ADH) Program for all Group adult foster Adult foster care inclusive care for Nursing facility care (GAFC) (AFC) the ( NF) elderly(PACE)</p><p>Signature______MD/NP/PA Name______Date completed </p>