First Name: Last Name:
Email:
Phone:
City,State:
Please look over this description. Make sure you are able to complete all requirements before submitting this application.
AND ABLE TO DO CLOSE EYE WORK
THERMOMETERS, CHARTS, ETC.
TASKS
I have read and understand that the physical, sensory, and mental requirements outlined below are necessary of the services to be performed. I affirm I am able to perform the service without limitation and have not knowingly withheld any information relating to these requirements.
Clincal Note: ===== 0123
Total Bed Bath: ===== 0123 Tub Bath: ===== 0123
Shower: ===== 0123 Sponge Bath: ===== 0123
Sitz Bath: ===== 0123 Hair Care: ===== 0123
Nail and Foot Care: ===== 0123 Skin Care: ===== 0123
Perineal Care: ===== 0123 Oral Care: ===== 0123
Denture Care: ===== 0123 Shave Patient ===== 0123
Asst. W/ Dressing: ===== 0123 Other:
Use of Cardiac Monitors: ===== 0123 Telemetry: ===== 0123
Perform 12-leed EKG: ===== 0123 Assist w/ Code ===== 0123
Acute MI: ===== 0123 Congestive Heart Failure: ===== 0123
Pre/Post Cardiac Cath: ===== 0123 Pre/Post Cardiac Sugery: ===== 0123
Aneursym: ===== 0123 Perm Pacemaker: ===== 0123
Temp Pacemaker: ===== 0123
Crutch Walking: ===== 0123 Cast Care: ===== 0123
Traction: ===== 0123 Amputation: ===== 0123
Skeletal Traction: ===== 0123 Arthoscopy: ===== 0123
Total Hip Replacement: ===== 0123 Total Knee Replacement: ===== 0123
Postitioning: ===== 0123 Transferring: ===== 0123
Walker: ===== 0123 Passive Range of Motion: ===== 0123
Active Range of Motion: ===== 0123 Walking W/ Assistance: ===== 0123
Walking with Supervision: ===== 0123 Hoyer Lift ===== 0123
Assist W/ Exercise Program: ===== 0123
Apply Noninvasive BP Monitor: ===== 0123 Monitor Noninvasive BP Monitor: ===== 0123 ===== 0123
Peripheral Pulses: ===== 0123 Discontinue Peripheral IV: ===== 0123
Intake and Output: ===== 0123 Ultrasound Doppler ===== 0123
Open/Monitor Airway: ===== 0123 Asst. W/ Intubation ===== 0123
Asst. W/ Extubation ===== 0123 02 Saturation Spot Checks ===== 0123
02 Saturation Monitors: ===== 0123 Incentive Spoirometry: ===== 0123
Nasal Cannula: ===== 0123 Face Masks: ===== 0123
Asthma/COPD: ===== 0123 Pre/Post Thoracic Sugery: ===== 0123
Tracheostomy: ===== 0123 Chest Tubes: ===== 0123
Neurological Eval: ===== 0123 Glascow Coma Scale ===== 0123
Assist W/ Lumbar Puncture: ===== 0123 Seizure Precautions: ===== 0123
Open/Close Head Surgery: ===== 0123 CVA: ===== 0123
Spinal Cord Injury ===== 0123 Craniotomy: ===== 0123
Drug Overdose: ===== 0123
Asst. W/ Nutritional Eval: ===== 0123 Asst. W/ Feeding: ===== 0123
Gastrostomy Tube Monitor/Feed: ===== 0123 Ostomy Care ===== 0123
GI Bleed: ===== 0123 Abdominal Wound: ===== 0123
Drains: ===== 0123
Straight/Foley Cath Female: ===== 0123 Straight/Foley Cath Male: ===== 0123
Obtain/Instruct Clean Catch Urine ===== 0123 Shunts/Fistuals: ===== 0123
Renal Failture: ===== 0123 Nephrectomy: ===== 0123
Renal Transplant: ===== 0123 Mastectomy: ===== 0123
Hysterectomy: ===== 0123 Prostate Surgery: ===== 0123
Diabetes: ===== 0123 AIDS ===== 0123
Multiple Traumas: ===== 0123 Burns: ===== 0123
Oncology: ===== 0123 Bone Marrow Transplant: ===== 0123
Liver Transplant: ===== 0123
Newborn: ===== 0123 Toddler (1-3): ===== 0123
Preschooler (3-5): ===== 0123 School Age (5-12): ===== 0123
Adolecents (12-18): ===== 0123 Young Adult (18-39): ===== 0123
Middle Adult (39-64): ===== 0123 Older Adult (64+) ===== 0123
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