Clinical Transition Plan - Illinois

State of Illinois - Department of Human Services
Clinical Transition Plan
IL462-4000 (N-4-11)
Page 4 of 8
Yes No
NoYes
Yes No
NoYes
Yes No
Yes No
Does the individual have chronic cardiovascular risk?
13. Cardiovascular Risk
Hypertension Arrhythmias CAD CHF Other:
14. Dental Issues
Abscess Caries Edentulous Dentures Peridontal Disease
Other
15. Allergies/Adverse Drug Reactions/Sensitivities
Does the individual have any adverse drug reactions/allergies?
If "Yes", list below, include type of reaction and date (if known):
ADR: Allergy: Sensitivity:
SECTION III. Medical Follow-up - Completed by Nursing
In the past year, has the individual been admitted to an acute facility/emergency room for medical condition?
1. Hospitalization/Clinical Follow-up
Date: Facility: Reason:
Reason:Facility:Date:
Reason:Facility:Date:
Reason:Facility:Date:
If more room is needed attach a separate sheet of paper.
2. Implanted Devices
Does the individual have an implanted device?
VNS:
Date inserted: Date last battery change:
Baclofen Pump:
Date inserted: Date last fill:
Pacemaker:
Date inserted: Date last battery change:
Portacath:
Date inserted: Date last flush:
Foley Catheter:
Date inserted: Last changed:
Catheter size:
3. Adaptive or Specialized Equipment
Does the individual require adaptive or specialized equipment (not previously listed)?
Glasses Hearing Aide
R: L: Both:
Adaptive eating utensils:
Type:
Other:
4. Protective devices?
Does the individual require protective devices?
Type:
5. Medical and Dental Support Services
Medical immobilization (Type & Indication):
Anxiolysis (Medication, Indication, Dose):
Desensitization Program:
If "Yes", attach support desensitization document.
Yes No
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