First Name

Last Name

CLIENT AUTHORIZATION TO RELEASE MEDICAL INFORMATION. My medical information may be released to the Montana Association for the Blind's 2024 Summer Orientation Program staff, nurses, and director.

Initials

Date you initialed the form

Doctor's Report

Date of last physical exam:

Note: exam must be within 6 months of June, 2024 Physical Examination:

Physical Examination:

Height

Weight

Pulse Rate:

Blood Pressure:

Excluding the client's visual problem can the client walk approximately 4 blocks without assistance, including gentle slopes?
Yes
No

Does the patient walk with the aid of a walker or mobility support?
Yes
No

Does the patient have a hearing loss?
Yes
No

If Yes, Which Ear or do Both Ears have hearing loss?

Does the patient have a heart condition?
Yes
No

Does it cause physical limitations?
Yes
No

If yes, please explain:

Does the patient have any allergies?
Yes
No

Does the patient have any of these conditions, if yes, Check the corresponding box
Arthritis
Asthma
Incontinence
Mental Disorders
Dementia
IBS-type syndrome
Diabetes
Controlled by: Insulin
Controlled by: Oral Preparation
Controlled by: Both
Controlled by: Diet

The patient will be attending a month-long, independence training program. Classes will run from 8am to 4pm. There will be some walking and standing involved. We will have a nurse on duty part-time. The student will be living and sharing bathrooms with other people.

Are there any other physical concerns we should be aware of?
Yes
No

If Yes, Please Explain?

Does the patient have any physical limitations excluding their vision?
Yes
No

Examining Physician Name:

Doctor's Initials

Today's Date

Phone