{note}Patient Call Assessment Template{endnote}
Date/Time: {formdate: LLL; name=Date} Telephone #: {formtext: name=Telephone}
Patient Name: {formtext: name=Patient Name} Patient ID: {formtext: name=Patient ID}
Caller's Name: {formtext: name=Caller Name}Relationship: {formmenu: spouse; caregiver; other; multiple=yes; name=Relationship}If Other: {formtext: name=Other Relationship}
**Hosp/fall (30d):** {formmenu: No; Yes; name=Hosp/Fall} {formtext: name=Hosp/Fall Details}
**Home vitals (BP/HR/Wt):** {formmenu: BP; Glucose; Weight; BP & Glu; Doesn't take vitals at home; Doesn't recall reading; multiple=yes; name=Vital}Frequency: {formmenu: Daily; Weekly; Monthly; Other; name=Vitals Frequency}If Other: {formtext: name=Vitals Other}
**SYMPTOMS**
Swelling: {formmenu: None; Hands; Legs; Feet; Ankles/Feet; Other; multiple=yes; name=Swelling Area}If Other: {formtext: name=Swelling Other}
**Diet:** {formmenu: Low salt; Low sugar; Other; multiple=yes; name=Diet Type} If Other: {formtext: name=Diet Other}
**Fluid intake:** {formtext: name=Fluid Intake} **Restriction:** {formtext: name=Fluid Restriction}
**Med/allergy changes**: {formmenu: No; Yes; name=Med Allergy Changes} {formtext: name=Med Allergy Details}
**Chest pain/tightness:** {formmenu: No; Yes; name=Chest Pain} {formtext: name=Chest Pain Details}
**SOB:** {formmenu: No; Yes; Occasionally; multiple=yes; name=SOB} With activity / Without activity: {formmenu: With activity; Without activity; Both; none; multiple=yes; name=SOB Type} {formtext: name=SOB Details}
**Fatigue:** {formmenu: No; Yes; name=Fatigue} {formtext: name=Fatigue Details}
**Headache/dizziness:** {formmenu: No; Yes; name=Headache Dizziness} {formtext: name=Headache Dizziness Details}
**Nausea/vomiting:** {formmenu: No; Yes; name=Nausea Vomiting} {formtext: name=Nausea Vomiting Details}
**Urinary issues (pain/burn/blood/urgency/odor):** {formmenu: No; Yes; name=Urinary Issues} {formtext: name=Urinary Issues Details}
Bowel change: {formmenu: No; Yes; name=Bowel Change} {formtext: name=Bowel Change Details}
**Muscle/joint pain:** {formmenu: No; Yes; name=Muscle Joint Pain} {formtext: name=Muscle Joint Pain Details}
**Sleep problems / daytime napping:** {formmenu: No; Yes; name=Sleep Problems} {formtext: name=Sleep Problems Details}
**Alcohol / Tobacco / NSAID:** {formmenu: Alcohol; Tobacco; NSAID; None; multiple=yes; name=Substance Use} {formtext: name=Substance Use Details}
**Active for at least 30 minutes daily:** {formmenu: No; Yes; name=Active 30 Min} {formtext: name=Active Details}
**Ambulation:** {formmenu: No; Yes; name=Ambulation} Type: {formmenu: Independent - no aid; Walker; Cane; Wheelchair; Bedbound; multiple=yes; name=Ambulation Details} {formtext: name=Ambulation Notes}
**Independent with daily activities:** {formmenu: No; Yes; name=Independent ADL} {formtext: name=ADL Details}
**Lives alone:** {formmenu: No; Yes; name=Lives Alone} **Support:** {formtext: name=Support Details}
**New providers/tests:**
{formparagraph: name=New Providers Tests}
**Misc / Notes:**
{formparagraph: name=Misc Notes}
**Permission to speak w/ other household member:** {formmenu: No; Yes; name=Permission Household} Name/Relationship: {formtext: name=Household Contact}
**Text message permission:** {formmenu: Yes; No; name=Text Permission}
