0929c Participant Medical Information, National Veterans Creat

OMB Number: 2900-0759
Expiration Date: Xxx, 20XX
Respondent Burden: 35 minutes

PARTICIPANT MEDICAL INFORMATION FORM
NATIONAL VETERANS CREATIVE ARTS FESTIVAL

(To be completed by Clinician, Physician, Psychiatrist, Nurse Practitioner or Physician Assistant and signed by the same)
PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17, Section 1710. VA
may disclose the information that you put on this form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in
the Privacy Act systems of records notices identified as 121VA19 “National Patient Databases - VA”. Providing the requested information is
voluntary. However, you will not be able to participate in the event without furnishing this information.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with
the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must
complete this application will average 35 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the
forms.
*Attention veteran: Please schedule an appointment with your primary provider as soon as possible. Bring this form to your appointment. Your
provider must complete this form. Please return this form along with your completed registration forms by

.

Dear Clinician: Your patient has been invited to attend the National Veterans Creative Arts Festival in
.
Be aware that the elevation in Reno, NV is about 4,505 feet above sea level. Activities that he/she may be engaging in include rehearsing and
performing music, dance, and drama acts or original writing selections for the public, or participating in visual art workshops, exhibits, and local art
gallery touring opportunities.
If you agree that this patient is able to participate in the above activities, we ask that you complete the following information. The information that
you provide will assist the medical team with providing appropriate care. Clinicians and nurses working with the Festival are provided to take care
of emergencies and illness only. Routine care is the participant's responsibility.
PATIENT'S NAME

SOCIAL SECURITY
NUMBER (Last 4 digits only)

PATIENT'S ADDRESS (City, State and Zip Code)

VA MEDICAL FACILITY WHERE PATIENT RECEIVES CARE

CELL PHONE NUMBER
(Include area code)

TELEPHONE NUMBER 2
(Include area code)

HEIGHT
(inches)

WEIGHT
(pounds)

PULSE

DATE OF BIRTH

BLOOD PRESSURE
/

IS PATIENT ALLERGIC TO ANYTHING?
(Please include food allergies) (If Yes, specify)

YES

NO

DOES PATIENT EXPERIENCE ANY ALLERGIC REACTION
TO MEDICATIONS? (If Yes, specify medications)

YES

NO

LIST ALL MEDICAL DIAGNOSES (If more room is needed, please attach a problem list)
1.

2.

3.

4.

DOES THE PATIENT HAVE ANY PHYSICAL LIMITATIONS?

YES

NO

DOES THE PATIENT USE A WHEELCHAIR?

YES

NO

IS IT A MOTORIZED WHEELCHAIR?

YES

NO

DOES PATIENT USE WHEELCHAIR MAJORITY OF
THE TIME? (If Yes, under what circumstances?)

YES

NO

OXYGEN REQUIRED?
(If Yes,check appropriate box)

YES

NO

NEBULIZER NEEDED?

YES

NO

CPAP USED?

YES

NO (If Yes, is CPAP with 02?)

ALL THE TIME

AT NIGHT ONLY

YES

PRN

NO

LIST CURRENT MEDICATIONS, DOSAGE, AND HOW OFTEN ADMINISTERED (May attach Health Summary that includes all current medications)
MEDICATION:

DOSAGE:

ADMINISTRATIONS:

MEDICATION:

DOSAGE:

ADMINISTRATIONS:

MEDICATION:

DOSAGE:

ADMINISTRATIONS:

MEDICATION:

DOSAGE:

ADMINISTRATIONS:

MEDICATION:

DOSAGE:

ADMINISTRATIONS:

VA FORM
MAR 2014

0929c

YES

SELF MEDICATED? (If No, patient MUST be accompanied by an attendant!)

NO

ANY SPECIAL ASSISTANCE REQUIRED IN ACTIVITIES OF DAILY LIVING?

LIST ANY SPECIAL ASSISTIVE EQUIPMENT PATIENT WILL NEED TO BRING

PATIENT REQUIRES AN ATTENDANT TO ATTEND THE
FESTIVAL IN

?

YES

NO

(If Yes, attendant's name)

In the examining clinician's opinion, the above individual
IS CLEARED TO ATTEND

IS NOT CLEARED TO ATTEND

SIGNATURE AND TITLE OF EXAMINING CLINICIAN

NAME AND ADDRESS OF EXAMINING CLINICIAN (Please print)

DATE

TELEPHONE NUMBER

RETURN ALL COMPLETED FORMS BY
TO:
Stephanie Torian
Host Site Coordinator (05/Vol)
VA Sierra Nevada Health Care System
975 Kirman Avenue
Reno, NV 89502
Phone: (775) 328-1411 / Fax: (775) 337-2276
Stephanie.Torian@va.gov

VA FORM 0929c, MAR 2014, PAGE 2