2015 LOURDES PILGRIMAGE 29 APRIL – 6 MAY, 2015 EVALUATION OF MEDICAL CONDITION AND NURSING CARE REQUIREMENTS OF PROSPECTIVE MALADE IT IS NECESSARY TO ANSWER ALL QUESTIONS. INSTRUCTIONS Malade applicant should complete Page 1 and pages 2-5 MUST be completed by treating physician or a member of the physician's staff (NOT by malade). It is not necessary to send additional medical information unless your treating physician deems it necessary for clarification of your medical history. Please print legibly (or type) all answers. The original completed and signed Medical Evaluation form must be submitted as part of the completed 2015 Malade Application packet (per Application Check List) by Friday, November 14, 2014. _____________________________________________________________________________________ Full Name of Prospective Malade Date of Birth _____________________________________________________________________________________ Address Preferred Phone _____________________________________________________________________________________ City State Zip _____________________________________________________________________________________ Sponsor’s Name Sponsor Phone # _____________________________________________________________________________________ Sponsor City Sponsor Region If you have any questions with regard to the Medical Evaluation Form please contact the Pilgrimage Chief Nurse, Joan Cincotta, RN 315.446.5543 (home), 315.420.9486 (cell) or [email protected] (email) Order of Malta, Federal Association, USA 1730 M Street, NW Suite 403 Washington, DC 20036-4517 Phone: 202.331.2494 | www.orderofmalta-federal.org Page 1 of 5 Name of Patient: ___________________________ Page 2 of 5 HISTORY OF PRESENT ILLNESS General Description of Disability _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Associated Medical or Surgical Conditions _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Medications Please list all your medications and include condition, dosage & schedule. Please attach a listing in this format if additional space is necessary. Important note: medical marijuana is prohibited on any international flight and is illegal in France . Medication Condition Dosage Schedule Name of Patient: ___________________________ Page 3 of 5 **ALLERGIES (medication and food) Also describe reaction(s)** This information is required _________________________________________________________________________________ _________________________________________________________________________________ DETAILED REVIEW OF SYSTEMS 1. CARDIOVASCULAR: Problem: No ____ Yes_____ If yes, specify: Chest Pain _____ Shortness of Breath______ Palpitations_____ Swelling of lower extremities _____ Blood Pressure _____ Stroke _____ Comments: __________________________________________________________________________________ 2. RESPIRATORY: Problem: No _____ Yes _____ If yes, specifiy: Cough _____ Shortness of Breath _____ Abnormal sputum _____ Other: _________________________________________________________________ 3. HEARING: Problem: No _____ Yes _____ If yes, describe: __________________________________________ 4. VISION: Problem: No _____ Yes _____ If yes, describe: ____________________________________________ 5. GASTRO-INTESTINAL: Problem: No _____ Yes _____ If yes, specify: _________________________________ Pain _____ Nausea _____ Vomiting _____ Ileostomy _____ Colostomy _____ Other: ______________________ 6. BOWEL: Problem: No _____ Yes _____ If yes, specify: _____________________________________________ Constipation _____ Diarrhea _____ Incontinence: frequent _____ occasional _____ Level of care: Self _____ Physical Assistance _____ Specify: _________________________________________ Comments: _________________________________________________________________________________ 7. URINARY: Problem: No _____ Yes _____ If yes, specify: Frequency _____ Pain _____ Incontinence: frequent _____ occasional _____ bedwetting _____ Assistive devices: Catheter _____ External _____ Indwelling _____ Other: _____________________________________________________________________________________ Level of care: Self _____ Physical Assistance _____ Specify: _________________________________________ Comments: _________________________________________________________________________________ 8. NUTRITION: Problem: No _____ Yes _____ If yes, describe: ________________________________________ Level of nutritional care needed: _________________________________________________________________ Special Diet: No _____ Yes _____ Specify: _______________________________________________________ Needs to be fed: No _____ Yes _____ Comments: __________________________________________________________________________________ Name of Patient: ___________________________ 9. Page 4 of 5 NEUROMUSCULAR Problem: Check all application items: Ambulatory _____ Ambulatory with limitation _____ Non-ambulatory _____ Amputation: No _____ Yes _____ if yes, describe: ______________________________ Paralysis: No _____ Yes _____ If yes, describe: ___________________________________________________ Seizures: No _____ Yes _____ If yes, type: _________________________ Frequency: __________________ Significant limitation of motion: No _____ Yes _____ If yes, describe: __________________________________ Supportive devices: Cast _____ Bandage _____ Brace _____ Describe: _________________________________ Comments: _________________________________________________________________________________ 10. HYGEINE / GROOMING: Level of care needed: ____________________________________________________ Bathing: Self _____ Assistance: Total _____ Partial _____ Dressing: Self _____ Assistance: Total _____ Partial _____ Hair: Self _____ Assistance: Total _____ Partial _____ 11. PSYCHIATRIC: Problem: No _____ Yes _____ If yes, specify: ________________________________________ ___________________________________________________________________________________________ Anxiety: ______________ Depression:______________ Mood Swings:______________ Irritability: __________ 12. SKIN: Problem: No _____ Yes _____ Pressure sores _____ Describe: ___________________________________________________________________________________ PHYSICAL EXAMINATION Height: _______________ Weight: _______________ Blood Pressure: ______________ Ears: Normal  _____________________________________________________________ Eyes: Normal  _____________________________________________________________ Nose: Normal  _____________________________________________________________ Throat: Normal  _____________________________________________________________ Lungs: Normal  _____________________________________________________________ Heart: Normal  _____________________________________________________________ Abdomen: Normal  _____________________________________________________________ Genitalia: Normal  _____________________________________________________________ Rectal: Normal  _____________________________________________________________ Skin: Normal  _____________________________________________________________ Extremities: Normal  _____________________________________________________________ Name of Patient: ___________________________ Page 5 of 5 Comments: _____________________________________________________________________________________ _______________________________________________________________________________________________ Diagnosis: _____________________________________________________________________________________ _______________________________________________________________________________________________ Specific Nursing Care Requirement: NONE  _____________________________________________________________________________________ _______________________________________________________________________________________________ Is this patient medically stable to travel to Lourdes, France? Yes _____ No _____ Will this patient require the use of a portable oxygen canister? Yes _____ No _____ Will this patient require the use of any electrical device? Yes _____ No _____ GENERAL INFORMATION Does this individual have difficulty walking long distance? Yes _____ No _____ Can this individual sit in a standard coach airline seat for a 9-hour flight? Yes _____ No _____ Does this individual speak English? Yes _____ No _____ IT IS NECESSARY TO ANSWER ALL THE QUESTIONS ABOVE. _____________________________________________________________________________________ Physician’s Signature Print Physician’s Name Dated _____________________________________________________________________________________ Physician’s Address _____________________________________________________________________________________ Physician’s Phone # Physician’s Fax Mobile/Pager _____________________________________________________________________________________ Physician’s Email Order of Malta, Federal Association, USA 1730 M Street, NW Suite 403 | Washington, DC 20036-4517 Phone: 202.331.2494 | www.orderofmalta-federal.org