Salud A Su Alcance

Division of Community Health Outreach

Carlene Duncan :Program Coordinator ckd9001@nyp.org

Telephone 212-342-1618

Fax 212-342 6049

NYPH 622 W. 168th St. VC10 Area C Rm 5

New York, NY  10032

Provider Information:
name:_________________

phone:________________

Email:_________________

Date:_________________

beeper #:______________

Practice Location:     AIM Clinic

Patient information:  Sex___   DOB_____ Ethinicity:__________ primary language:_________

MRN: ________________________                  

First Name:___________________
Last Name:____________________

Address:______________________

phone:________________________

List of Meds:

health profile:  DM ____type_____ HTN______Depression________

nephropathy________neuropathy________retinopathy________

CV _______________  other________________________

last hbA1c date:_____________Value:________________

Other patient concerns

__compliance

__education

__memory impairment

__other________________________________________

How often do you want outreach workers to visit the pt:
___once/week                            _____ twice/week