Pre-Op Discharge Planning Form

Step 2: Complete and Submit the Joint University Pre-Op Discharge Planning Form

To complete your Online Pre-Surgical Education Course, please follow these 6 STEPS.

Need Help?

Complete and Submit the Joint University Pre-Op Discharge Planning Form, then move on to Step 3.

(773) 564-5680

Weiss Memorial Hospital
4646 N. Marine Drive
Chicago, IL 60640

Complete Step 2 of your six-step online pre-surgical education course.

Preoperative and Risk Assessment Form

First Name *

Last Name *

Work Phone

Cell Phone

Zip

Surgery Date

Living Arrangements (check all that apply)

House

Apartment

Live Alone

Live with Spouse/Family/Friend

Caregiver Assistance

Bathtub

Shower

Pets

Elavator

Stairs

Floor your bedroom is on

Select all that apply

A walker will fit into the bathroom

There are stairs entering the shower

There are stairs leading into the kitchen

There are stairs at the front door

Phone Number of Caregiver

Select all that apply

I have pets

My caregiver will be responsible for my pets during recovery

My caregiver will keep pets away from my incision

I have had Home Health Care before

Health Care Agency Name

Do you use oxygen at home?

Yes, I use oxygen at home

No, I do not use oxygen at home

How often and who supplies your tank?

Select all that apply

If I require outpatient physical therapy, I have someone who can drive me

I have someone that can drive me for follow-up doctor appointments

I would like assistance in arranging transportation post hospitalization (There may be a fee)

There will be someone home 24 hours a day for one week when I return home from surgery

Insurance & Health Information

(check/answer all that apply)

What type of insurance do you have?

Do you have secondary insurance?

Yes

What insurance?

If you have a Workers Comp Case Manager or number, please provide details.

Would you like to speak to a financial counselor about questions or concerns you may have about your insurance? You can reach our financial counselors directly at (773) 564-7563.

Yes

Preferred Pharmacy Name

Preferred Pharmacy Phone Number

Primary Care Doctor Name

Primary Care Doctor Phone Number

If you have been in a Skilled Nursing Facility, which one?

If it is necessary for you to go to a Skilled Nursing Facility after surgery, do you have a preference? If yes, which one?

Depending on insurance

Yes I have someone that can go coverage and your surgeons preference, we may give you a list of Skilled Nursing Facilities to visit. Is there someone that can go with you?

No, I do not have someone that can go with me

Do you have issues with anxiety or any other conditions that require medication to relax? If yes, what is the condition and the medication?

Yes

Condition and Medication

Have you ever been told you have an infection such as those listed below?

Yes

MRSA Screen

Yes, I have had a MRSA Screen

No, I have not had a MRSA Screen

Test Results

Positive

Negative