Encounters UIDHiddenApproved? (Admin-only) Approved Badge Number(Required)Date of Encounter(Required) MM slash DD slash YYYY Type of Encounter(Required) EMS/Paramedicine Run 48 Hour Discharge Follow Up Care Medication Reconciliation Date of Discharge(Required) MM slash DD slash YYYY Encounter Necessity(Required) Necessary Unnecessary Was this visit necessary?Type of Unnecessary Healthcare Use Non-Emergent 911 Call Non-Emergent Emergency Department Visit Readmitted to the Hospital within 30 Days of Initial Discharge Patient Name(Required) First Name - Required Last Name - Required Date of Birth(Required) MM slash DD slash YYYY Enrolled in Program(Required) Yes No Age(Required)Select0-1718-2425-3536-4546-5455-6465 or olderPrefer not to answerGender(Required)SelectFemaleMaleTransgenderPrefer not to answerRace(Required)SelectAmerican Indian or Alaska NativeAsianBlack or African AmericanHawaiian Native or other Pacific IslanderWhiteMore than one raceAnother race or ethnicityPrefer not to answerEthnicity(Required)SelectHispanicNon-HispanicPrefer not to answerAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County(Required) PhonePrimary Language(Required) English Other Does the individual meet any of the following criteria?(Required) Current active enrollment in MEDICAID/HIP Current active enrollment in SNAP/Food Stamps Current active enrollment in TANF Residing in a household at or below 200% of poverty per the HHS Poverty Guideline N/A Education Level(Required)SelectLess than 9th Grade9-12th Grade, No DiplomaHigh School Diploma/GEDSome College, No DegreeAssociate DegreeBachelor DegreeGraduate or Professional DegreePrefer not to answerDisabled(Required) Yes No Type of Disability(Required) Mobility/Physical Spinal Cord (CSI) Head Injury (TBI) Vision Hearing Cognitive/Learning Psychological Invisible Other Substance Use(Required) Yes No Type of Substance Use(Required) Alcohol Prescription & OTC Medicine Heroin Cocaine Marijuana Cigarettes and Other Tobacco Products Other Mental Illness(Required) Yes No Type of Mental Illness(Required) Anxiety Depression Bipolar Disorder Post-Traumatic Stress Disorder Schizophrenia Eating Disorder Disruptive Behavior / Dissocial Disorder Neuro-developmental Disorder Other Referrals Provided(Required) Yes No Type of Referrals Provided(Required) Food/Food Pantry Harm Reduction HCV Testing HIV Linkage HIV Re-Engagement HIV Testing Immunizations Medical Insurance Medical Care Mental Health Narcan Paramedicine Program Peer Recovery Pregnancy Test Prenatal Care PrEP Primary Care Smoking Cessation STD Testing Substance Use Treatment Transportation Services Wound Care Other Case Note(Required)
