Prepare to Care Workbook | Page 22

MEDICAL HISTORY

MEDICAL INTERVENTIONS

Type of Medical Intervention( check if applicable)

Comments

Feeding tube

Tracheostomy

Ventilator

Suctioning

Pacemaker

Catheter

Other

LAST VISION ASSESSMENT Date: / / Significant findings:

DRIVING ASSESSMENT Date: / / Significant findings:

SWALLOWING ASSESSMENT Date: / / Significant findings:

CurePSP Prepare to Care 21