SELECT patient.Last_Name_M0040 AS Last_Name, patient.First_Name_M0040 AS First_Name, patient.Middle_Initial_M0040 AS Middle, Assessment_Completed_M0090, Assessment_New.Psy_Nursing_M0630, Assessment_New.Emergent_Care_Reason_M0840, Assessment_New.Grooming_M0640, Assessment_New.Grooming_M0640p, Assessment_New.Urinary_INcont_M0520, Assessment_New.Patient_Behav_freq_M0620, Assessment_New.Home_Safety_Assess, Assessment_New.Urinary_INcont_when_M0530, Assessment_New.M0420_Assess, Assessment_New.Record_Created_By FROM #Request.prefix_db_agency#.Assessment_New INNER JOIN #Request.prefix_db_agency#.patient ON (Assessment_New.Patient_ID=patient.Patient_ID) WHERE Assessment_New.Assessment_ID='#session.cs.AssessmentId#' select Diagnosis_ID,Diagnosis,Short_Diagnosis,Text_ICD,Severity,CONVERT(Diagnosis.Dx_Order, CHAR(10)) as Dx_Order,Primary_Diagnosis,Secondary_Diagnosis,DG_Type from #Request.prefix_db_agency#.Diagnosis where Assessment_ID='#session.cs.AssessmentId#' and M0230_Link like '%M0230%' and M0230_Link is not null order by Dx_Order asc

#session.agencyname#	Date Completed #DateFormat(Form.Assessment_Completed_M0090,"mm/dd/yyyy")#
Medical Social Worker Evaluation	By #Form.Record_Created_By#
#Form.First_Name# #Form.Last_Name#

Reason for social worker referral

#Form.Emergent_Care_Reason_M0840#

Pain Assessment

Pain Level

#Form.Psy_Nursing_M0630#

Pain Characteristics

#replace('#Form.Grooming_M0640#',',',' ',"ALL")# #replace('#Form.Grooming_M0640#','!',' ',"ALL")#

Pain Threshold

#Form.Grooming_M0640p#

Living Situation

#replace('#Form.Urinary_INcont_M0520#',',',' ',"ALL")# #replace('#Form.Urinary_INcont_M0520#','!',' ',"ALL")#

Mental Status

#replace('#Form.Patient_Behav_freq_M0620#',',',' ',"ALL")# #replace('#Form.Patient_Behav_freq_M0620#','!',' ',"ALL")#

Home safety Issues Mark all that apply

#Form.Home_Safety_Assess#

Financial

#Form.Urinary_INcont_when_M0530#

Physical Assessment

#Form.M0420_Assess#

Physician Signature: ____________________________________________________

Page #cfdocument.currentpagenumber# Medical Social Worker Evaluation for #Form.First_Name# #Form.Last_Name#