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Patient Form

Referal Form

Thank you for referring your patient to Tufts Medical Center. Please provide us with a brief history and information about the patient.

About the Patient
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Interpreter Needed

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Patient Medical History
Diabetes

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GI Disorder
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Irregular Heart Beat

Heart Murmur (type)

Mitral value prolapse

Valve replacement

Pacemaker/Implanted cardioverter defribilator (CD)

Hypertension/High Blood Pressure

Vascular grafts

Hepatitis/Jaundice

Kidney Disease

Lung/Breathing problems

Asthma

Emphysema

Sleep Apnea

Neurological Disoder

Musculoskeletal disorder

Bleeding disorders

Vision/Hearing loss

Glaucoma

Pregnant

Arthritis

Seizure Disoder

Prosthetic Joints

Cancer

Alcohol Intake

Tobacco

Are you a victim of domestic violence?

Do you have a Health Care Proxy?

Glasses/Contact Lenses

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Hearing Aids

Able to ambulate

Cane

Wheel Chair

Surgical History
*if applicable
*if applicable
Allergies

Include Latex, Iodine, Tape

Medications
Have you taken any medications such as narcotics, hynotics or sedatives with in the last 24 hours?

if applicable
*if applicable
Adult Ibuprofin
Date Discontinued Aspirin
*if applicable
Aspirin
Date Discontinued Anticoagulants
*if applicable
Anti-Inflammatory (NSAIDS)

Contact Information