GAMAL F. GHALY MD M.P.HDiplomat Certified in Internal Medicine

PATIENT INFORMATION FORM

PATIENT INFORMATIONEmail address:.PREFERRED LANGUAGE WHO REFERRED YOU TO US:

LAST NAME SOCIAL SECURITY #FIRST M.l. DATE OF BIRTH

ADDRESS ZIPCITY STATE

HOME PHONE CELL PHONE WORK PHONE

SEX ETHNICITY(RACE)MARITAL STATUS RELIGION

DO YOU WORK: Y/N: IF YES PLEASE COMPLETE EMPLOYER INFORMATIONEMPLOYER ADDRESS CITY ZIPSTATE

EMERGENCY OR OTHER CONTACT PERSONLAST NAME FIRST CONTACT PHONE NUMBER RELATIONSHIP TO PATIENT

INSURANCE INFORMATION/GUARANTORLAST NAME FIRST M.l. DATE OF BIRTH SOCIAL SECURITY#

ADDRESS CITY STATE PHONEZIP

PRIMARY INSURANCE INFORMATION POLICY OR ID NUMBER GROUP NUMBER

PATIENT'S RELATIONSHIP TO INSURED

SECONDARY INSURANCE INFORMATION POLICY OR ID NUMBER GROUP NUMBER

PATIENT'S RELATIONSHIP TO INSURED

I hereby authorize payment directly to Gamal F. Ghaly MD, MPH otherwise payable to me, but not to exceed the charge shown. I understand that I am financially responsible for all charges not covered by this authorization a copy of this assignment is as valid as the original.I request that payment of authorized Medicare benefits be made either to me or on my behalf to Gamal F. Ghaly MD, MPH for any services furnished me by that physician/supplier. I authorize any holder of medical information and its agents for information needed to determine these benefits payable for related services.

I HAVE READ THE ABOVE AND HEREBY CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLDEGE

Signature

PATIENT AND OR RESPONSIBLE PERSON DATE

HAVE YOU RECENTLY HAD THE FOLLOWING: CIRCLE "YES" OR "NO”; IF IN DOUBT LEAVE BLANK

PATIENT NAME: DATE:PRINT NAME

GENERALTIRE EASILY, WEAKNESS MARKED WEIGHT CHANGE NIGHT SWEATS PERSISTENT FEVER SENSITIVITY TO HEAT SENSITIVITY TO COLD

ABDOMINAL DISTRESS BELCHING OR EXCESS GAS ABDOMINAL ENLARGEMENT NAUSEA VOMITING

VOMITING OF BLOOD RECTAL BLEEDING TARRY STOOLS DARK URINE JAUNDICE CONSTIPATION DIARRHEA HEMORRHOIDS NEED FOR LAXITIVES

GENTOURINARY SYSTEM INCREASE IN FREQUENCY

OF URINATION (DAY)

INCREASE IN FREQUENCY OF URINATION (NIGHT)

FEEL NEED TO URINATE WITHOUT MUCH URINE

UNABLE TO HOLD URINGE PAIN OR BURNING BLOOD IN URINE ALBUMINURIA IMPOTENCE LACK OF SEX DRIVE PAIN WITH INTERCOURSE

ENDOCRINETHYROID TROUBLE ADRENAL TROUBLE CORTISONE TREATMENT DIABETES

LOCOMOTOR MUSCLE CRAMPS MUSCLE WEAKNESS PAIN IN JOINTS SWOLLEN JOINTS STIFFNESS

DEFORMITY OF JOINTS NERVOUS SYSTEM

HEADACHES DIZZINESS FAINTINGCONVULSIONS OR FITS NERVOUSNESS DEPRESSION CHANGE IN SENSATION MEMORY LOSS POOR COORDINATION WEAKNESS OR PARALYSIS

SLEEP DISORDERS SNORING

EXCESSIVE SLEEPINESSPAUSES IN BREATHING WHILE SLEEPINGINSOMINIASLEEPLESSNESS

YES NOYES NO YES NOYES NO YES NOYES NO YES NOYES NO YES NO YES NO

YES NO

YES NO

YES NOSKIN YES NO

ERUPTIONS (RASH) CHANGE IN COLOR CHANGE IN HAIR CHANGE IN NAILS

YES NO YES NO YES NO YES NO

YES NO

YES NO YES NO YES NO YES NO YES NO

EYESTROUBLE SEEING EYE PAIN INFLAMED EYES DOUBLE VISION WORN GLASSES

YES NO

YES NO

YES NO

YES NO YES NOYES NO

EARS YES NOLOSS OF HEARING RINGING IN EARS DISCHARGE

YES NONOYES YES NO

YES NO YES NO YES NO YES NO YES NO YES NO YES NO

YES NONOSE

LOSS OF SMELL FREQUENT COLDS OBSTRUCTION EXCESS DISCHARGE NOSEBLEEDS

MOUTH SORE GUMS SORENESS OF TONGUE DENTAL PROBLEMS

THROATPOSTNASAL DRAINAGESORENESS OF TONGUEHOARSENESSBREASTLUMPSDISCHARGE

CARDIO-RESPIRATORY SYSTEM COUGH, PERSISTING SPUTUM (PHLEGM)BLOODY SPUTUM WHEEZINGCHEST PAIN OR DISCOMFORTPAIN ON BREATING

SHORTNESS OF BREATHDIFFICULTY BREATHING WHILE LYING DOWN

SWELLING OF ANKLESBLUISH FINGERS OR LIPSHIGH BLOOD PRESSURE

PALPITATIONSVEIN TROUBLEDIGESTIVE SYSTEMCHANGE IN APPETITE

DIFFICULTY SWALLOWINGHEARTBURN

YES NO YES NO YES NO YES NO YES NO

YES NO YES NO YES NO

YES NO YES NO YES NO YES NO

YES NO YES NO YES NO

YES NO YES NO YES NO YES NO YES NO YES NO

YES NO YES NO

YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO

YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO

YES NO YES NO YES NO YES NO YES NO

YES NO YES NO YES NO

GAMAL F GHALY MD, M.P.H. 14114 BUSINESS CENTER DR., SUITE G

MORENO VALLEY, CA 92553 PH: 951 656.5333 FX: 951 656.6789

PATIENT MEDICAL INFORMATION FORM

PLEASE FILL OUT BOTH SIDES OF THIS FORM

NAME: DATE:

FAMILY HISTORY - HAS ANY BLOOD RELATIVE HAD ANY OF THE FOLLOWING:

CIRCLE "YES OR "NO" - IF YES, WHAT IS RELATIONSHIP

YES NO ____________________

YES NO ____________________

YES NO ____________________

YES NO ____________________

YES NO ___________________

YES NO ____________________

YES NO ___________________

YES NO ____________________

YES NO ____________________

YES NO ___________________

YES NO ___________________

YES NO ____________________

YES NO

PERSONAL HISTORYBIRTHPLACE:________

RACE:______________

DATE OF BIRTH:

ANEMIA

BLEEDING TENDENCY HEART DISEASE HIGH BLOOD PRESSURE CHRONIC LUNG DISEASE KIDNEY DISEASE

AVERAGE PER DAY:

ALCOHOL (WHAT TYPE & HOW OFTEN) TOBACCO (HOW OFTEN)

TEA, COFFEE (DECAF OR CAFFINATED) ASTHMA

MENTAL ILLNESS

PERSONAL PAST MEDICAL HISTORY CIRCLE "YES" OR "NO" DIABETES

THYROID TROUBLE PEPTIC ULCER CANCER OTHER

HAVE YOU EVER HAD:TUBERCULOSIS

CANCER

Type:_________ARTHRITIS BACK PAIN BRONCHITIS EMPHYSEMA/COPD DIABETES

OPERATIONS:TONSILS

APPENDIX

YEAR

YES NO YES NO

YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO

GALL BLADDER STOMACHYES NO

YES NO MEDICATIONS YOU TAKE (INCLUDE VITAMINS & HERBS DOSE

BREAST

UTERUS AND/OR C

PROSTATE

HERNIA

YES NO DRUG NAME DIRECTIONS FOR TAKING MEDICINEYES NO

YES NO

HIGH BLOOD PRESSURE HEART DISEASE

YES NO THYROID

YES NO CABG YES NO YES NOCHF YES NO HEART

CAD/VALVE

ANEMIA

HEPATITIS

YES NO Type:_ OTHERYES NO YES NO

YES NO

Type:____

KIDNEY DISEASE GLAUCOMA HIGH CHOLESTEROL DEPRESSION MENTAL DISORDERS THYROID DISORDERS

HypothyroidHyperthyroid

ALLERGIES

(ALLERIC TO:) PENICILLIN SULFA

OTHER DRUGS

YES NO

YES NO YES NO

YES NO YES NO YES NOYES NO GYN - OB (WOMEN)

STARED PERIOD AT AGE: DATE OF LAST PERIOD: NUMBER OF PREGNANCIES: NUMBER OF MISCARRIAGES: NUMBER OF BIRTHS:

OTHER:

YES NO YES NO

YES NO LIST

YES NO

YES NO FOOD YES NO

YES NO LIST

OTHER:

SCREENING TESTSCOLONOSCOPY Date:__________

LIST

YES NO (TO BE COMPLETED BY PATIENT)

WHAT IS THE MAJOR REASON FOR TODAY'S VISIT?IMMUNIZATIONS: TETANUS Date:___________

MAMMOGRAM YES NO YES NO

Date:

EYE EXAM YES NO FLU YES NO

Date: Date:PAP YES NO PNEUMONIA

Date:______

SHINGLES Date:______

YES NO

Date:_______

TB SCREENING Date:_______

YES NO YES NO

GAMAL F. GHALY MD, M.P.H 14114 BUSINESS CENTER DR., SUITE G

MORENO VALLEY, CA 92553 PH: 951 656.5333 FX: 951 656.6789

j: : ;

Gamal F. Ghaly MD 14114 Business Center Dr., Ste. G

Moreno Valley, CA 92570 PH: 951 656-5333

FX: 951 656-6789

Permission to Release Information to Family Members

give permission for the following members of my family to have permission to discuss with the doctor or have copies of my medical records released to said family member.

I,

The following names are:

Date of BirthPrint Name

Date of BirthPrint Name

Date of BirthPrint Name

Print Name Date of Birth

Patient's Printed Name Date

Patient Signature

GAMAL F GHALY MD MPH

14114 Business Center Dr.; Ste. G

Moreno Valley, CA 92553

Phone: 951 656-5333 Fax: 951 656-6789

PHARMACY USED BY PATIENT

Patient Name:

DOB:

Pharmacy Name:

Pharmacy Address:

Pharmacy Phone #:

: ■ *11

GAMAL F GHALY MD MPH

A Professional CorporationDiplomat Certified by the American Board of Internal Medicine

14114 Business Center Drive, Suite G

Moreno Valley, CA 92553 Phone: (951) 656-6789 Fax: (951) 656-6789

NOTICE TO CONSUMER

Medical doctors are licensed and regulated by the Medical Board of California

1 800 633-2322

I acknowledge the above statement:

Patient name Patient signature Date

Witness

GAMAL F GHALY MD MPH, INC

14114 Business Center Dr., Ste. G

Moreno Valley, CA 92553

Phone: 951 656-5333 Fax: 951 656-6789

PRIVACY NOTICE ACKNOLWLEDGEMENT

I understand that as part of my healthcare this organization originates and maintains health records describing my health history, symptoms, examinations and test results, diagnosis, treatment and plans for any future care of treatments. I understand that this information serves as:

A basis for planning my care and treatmentA means of communicating among many of the health care professionals who contribute to my careA source of information for applying my diagnosis and surgical information to my bill A means by which a third-party payer can verify that services billed were actually providedAnd a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided with a notice of privacy practices (privacy notice) which provide a more complete description of information uses and disclosure. I understand that I have the right to review the notice prior to signing this acknowledgment. I understand that the organization reserves the right to change their notice of privacy practices and that prior to implementation a copy will be mailed. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations and that the organization is not required to agree to the restrictions requested.

I acknowledge receipt of the policy practices

Printed Name:

Signature of Patient:

Date:

AUTHORIZATION FOR USE OR DISCLOSURE

OF MEDICAL RECORDS INFORMATION

I HEREBY AUTHORIZE THE PHYSICIAN AND/OR HEALTHCARE ORGANIZATION:

PHONE NUMBERNAME OF PREVIOUS DOCTOR

CITYADDRESS

STATE ZIP CODE

RELEASE RECORDS AND information TO: IF OVER 20 PAGES SEND TO: office255front(5)gmail.com

6AMAL F GHALY, MD, MPH, INC A PROFESSIONAL CORPORATION

14114 BUSINESS CENTER DRIVE, STE. G MORENO VALLEY, CA 92555

PH: (951) 656-5333 FAX: (951) 656-6789

PATIENT NAME DATE OF BIRTH

ADDRESS PHONE

DURATION: THIS AUTHORIZATION SHALL BECOME EFFECTIVE IMMEDIATELY AND SHALL REMAIN IN EFFECT FOR6 MONTHS.

REVOCATION: THIS AUTHORIZATION IS ALSO SUBJECT TO WRITTEN REVOCATION BY THE UNDERSIGNED AT ANY TIME BETWEEN NOW AND THE DISCLOSURE OF INFORMATION BY THE DISCLOSING PARTY. WRITTEN REVOCATION WILL BE EFFECTIVE UPON RECEIPT, BUT WILL NOT BE EFFECTIV E TO THE EXTENT THAT THE REQUESTER OR OTHER HAVE ACTED IN RELIANCE UPON THIS AUTHORIZATION

REDISCLOSURE: I UNDERSTAND THAT THE REQUESTER MAY NOT LAWFULLY FURTHER USE OF DISCLOSURE OF HEALTH INFORMATION UNLESS ANOTHER AUTHORIZATION IS OBTAINED FROM ME OR UNLESS DISCLOSURE IS SPECIFICALLY REQUIRED OR PERMITTED BY LAW.

SPECIFY RECORDS: PLEASE CHECK WHICH TYPE OF INFORMATION IS TO BE DISCLOSED:

ALL MEDICAL INFORMATION PSYCHIACTRIC INFORMATION

DRUG/ALCOHOL HIV TEST RESULTS

SIGNATURE OF PATIENT DATE

Advance Directives and Your Right to Make Medical Decisions

Here we’ll explain your right to make healthcare decisions and how you can plan for your medical care if you are unable to speak for yourself in the future. This can increase your control over your medical treatment.

Who decides about my treatment?Your doctors will give you information and advice about treatment. You can say “Yes" to treatments you want. You can say “No" to any treatment that you don’t want - even if the treatment might keep you alive longer.

How do I know what I want?Your doctor must tell you about your medical condition and about what different treatments and pain management alternatives can do for you. Many treatments have “side effects.” Your doctor must offer you information about problems that a treatment is likely to cause. Often, more than one treatment might help - and people have different ideas about which is best. Your doctor can tell you which treatments are available, but your doctor can’t choose for you. You make that choice, depending on what is important to you.

Can other people help with my decisions?Yes. Patients often ask relatives and close friends for help in making medical decisions. They can help you think about the choices you face. You can ask the doctors and nurses to talk with your relatives and friends, and they can ask the doctors and nurses questions for you.

Can I choose a relative or friend to make healthcare decisions for me?Yes. You can tell your doctor that you want someone else to make healthcare decisions for you. Ask the doctor to note in your medical record the name of the person who will be your healthcare “surrogate.” The surrogate only makes decisions for you during treatment for your current illness or injury or, if you are in a medical facility, until you leave the facility.

What if I become too sick to make my own healthcare decisions?If you haven’t named a surrogate, your doctor will probably ask your closest available relative or friend to help decide what is best for you. That works most of the time, but sometimes everyone doesn’t agree about what to do. That’s why it is helpful if you can say in advance what you want to happen if you can’t speak for yourself.

Do I have to wait until I am sick to express my wishes about health care?No. In fact, it is better to choose before you are very sick or have to go into a hospital, nursing home, or other healthcare facility. You can use an Advance Health Care Directive to say who you want to speak for you and what kind of treatments you want.

These documents are called “advance” because you prepare one before healthcare decisions need to be made. They are called “directives” because you are directing them about what you want done.

In California, the part of an advance directive you can use to appoint an agent to make healthcare decisions is called a Power of Attorney for Health Care. The part where you can express what you want done is called an Individual Health Care Instruction.

Advance DirectivesAn advance directive is a document that puts your wishes about your health care in writing, and informs your family, doctor and others involved in your care of your wishes if you become unable to make decisions or communicate for yourself. In addition to having your wishes respected, filling out an advance directive takes some of the pressure and responsibility off the shoulders of loved ones; they don’t have to guess about what you would have wanted. Anyone 18 and older can make out an advance directive.

Living WillYou may have heard the term living will. This is a written document that specifies what types of medical treatments are desired. More specific living wills may include information regarding someone’s feelings about treatments such as pain relief, antibiotics, hydration, feeding, and the use of ventilators or resuscitation.

Advance DirectiveAn advance directive has three parts. In the first part you can name a person to be your agent (and alternates in case your agent is not available) to legally make health care decisions on your behalf. This person is called a Durable Power of Attorney for Health Care.

In the second part, as in a Living Will, you can detail the treatments you would and would not want, and under what circumstances—things like feeding tubes, ventilators, and what to do if your heart and breathing stop. In the third part you can address whether you want your body donated to science.

If you don’t want an advance directive, you will still get medical treatment.

Thinking It Over

Developing an advance directive should involve thinking about what you would want for yourself, and then talking those ideas over with people you trust. What would be your highest priority? It might be to be free of pain, or to not be on a ventilator (breathing machine), or to have everything done to keep you alive as long as possible.

Choosing An Agent

When you are choosing an agent, you should consider people over 18 years old who know you and you believe will honor and respect your values and wishes, even if your wishes are different from theirs. The agent must be willing to accept the responsibility, be geographically available, and have a strong enough personality to ask questions and stand up for you.

The agent you appoint may be a family member, a friend, or even your attorney. But it cannot be the owner or operator of a residential care facility where you live, or one of your health care providers, unless the person is related to you or is a co-worker.

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The agent you name usually makes decision only after you lose the ability to make them yourself. But, if you wish, you can state in the advance directive that you want the agent to begin making decisions immediately.

ACKNOWLEDGMENT OF PATIENT INFORMATION ON ADVANCE DIRECTIVES

Name:

Address:

Date of Birth:Social Security #:

I have received written information on state law, and the hospital’s written policy, advising me of my right to make decisions concerning my medical care, including the right to accept or refuse medical or surgical treatment, and formulate advance directives (declaration and/or durable power of attorney for health care decisions).

1.

□ yesD no

2. I have formulated an advance directive:

□ yesD NODeclaration

Durable Power of Attorney

for Health Care Decisions □ yesD NO

If YES is marked, I have provided a copy of my advance directive to the hospital (if I haven’t, I will provide a copy to the hospital as soon as possible)

__ check here if copy is provided

Comments: (hospital follow up efforts if the patient cannot receive the advance directives information upon admission or does not bring in a copy of the advance directive if he/she states he/she has one):__________________________

Although the patient is instructed to bring in a copy of his/her advance directive to be placed in the medical record, the substance/instructions of patient’s advance directive states:_____________________________________________

I understand I will not be discriminated against on my provision of care whether or not 1 have an advance directive.

(Date)(Patient's Signature)

(Family or Other (if patient is unable to sign) (Date)

(Hospital Representative) (Date)

HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY

Physician Orders for Life-Sustaining Treatment (POLST)Date Form Prepared:Patient Last Name:First follow these orders, then contact

Phvsician/NP/PA. A copy of the signed POLST form is a legally valid physician order. Any section not completed implies full treatment for that section. POLST complements an Advance Directive and is not intended to replace that document

Patient Date of Birth:Patient First Name:

Medical Record #: (optional)Patient Middle Name:EMSA #111 B (Effective 1/1/2016)*

Cardiopulmonary Resuscitation (CPR): if patient has no pulse and is not breathing. __________________ If patient is NOT in cardiopulmonary arrest, follow orders in Sections B and C.D Attempt Resuscitation/CPR (Selecting CPR in Section A requires selecting Full Treatment in Section B)

□ Do Not Attempt Resuscitation/DNR (Allow Natural Death)

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Medical Interventions: If patient is found with a pulse and/or is breathing.B□ Full Treatment - primary goal of prolonging life by all medically effective means.

In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated.

□ Trial Period of Full Treatment.

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□ Selective Treatment - goal of treating medical conditions while avoiding burdensome measures.In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care.

D Request transfer to hospital only if comfort needs cannot be met in current location.

□ Comfort-Focused Treatment - primary goal of maximizing comfort.Relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location.

Additional Orders:

Artificially Administered Nutrition: Offer food by mouth if feasible and desired.C□ Long-term artificial nutrition, including feeding tubes. Additional Orders:□ Trial period of artificial nutrition, including feeding tubes._______________□ No artificial means of nutrition, including feeding tubes.

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Information and Signatures:d□ Patient (Patient Has Capacity) □ Legally Recognized DecisionmakerDiscussed with:

, available and reviewed -> Health Care Agent if named in Advance Directive:Name: ________________________________Phone: _______________________________

□ Advance Directive dated_____□ Advance Directive not available□ No Advance DirectiveSignature of Physician / Nurse Practitioner / Physician Assistant (Physician/NP/PA)My signature below indicates to the best of my knowledge that these orders are consistent with the patient's medical condition and preferences.

Physician/PA License #, NP Cert. #:Print Physician/NP/PA Name: Physician/NP/PA Phone #:

Date:Physician/NP/PA Signature: (required)

Signature of Patient or Legally Recognized DecisionmakerI am aware that this form is voluntary. By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form.Print Name: Relationship: (write self if patient)

Signature: (required) Date:FOR REGISTRY

USE ONLYMailing Address (street/city/state/zip): Phone Number:

SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED•Form versions with effective dates of 1/1/2009, 4/1/2011 or 10/1/2014 are also valid

HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARYPatient Information

Gender:Date of Birth:Name (last, first, middle):M F

Preparer Name (if other than signing Physician/NP/PA)NP/PA’s Supervising PhysicianPhone#:Name: Name/Title:

Additional Contact □ NonePhone #:Name: Relationship to Patient:

Directions for Health Care ProviderCompleting POLST• Completing a POLST form is voluntary. California law requires that a POLST form be followed by healthcare providers,

and provides immunity to those who comply in good faith. In the hospital setting, a patient will be assessed by a physician, or a nurse practitioner (NP) or a physician assistant (PA) acting under the supervision of the physician, who will issue appropriate orders that are consistent with the patient's preferences.

• POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts.

• POLST must be completed by a health care provider based on patient preferences and medical indications.• A legally recognized decisionmaker may include a court-appointed conservator or guardian, agent designated in an Advance

Directive, orally designated surrogate, spouse, registered domestic partner, parent of a minor, closest available relative, or person whom the patient’s physician/NP/PA believes best knows what is in the patient’s best interest and will make decisions in accordance with the patient’s expressed wishes and values to the extent known.

• A legally recognized decisionmaker may execute the POLST form only if the patient lacks capacity or has designated that the decisionmaker’s authority is effective immediately.

• To be valid a POLST form must be signed by (1) a physician, or by a nurse practitioner or a physician assistant acting under the supervision of a physician and within the scope of practice authorized by law and (2) the patient or decisionmaker. Verbal orders are acceptable with follow-up signature by physician/NP/PA in accordance with facility/community policy.

• If a translated form is used with patient or decisionmaker, attach it to the signed English POLST form.• Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid. A copy

should be retained in patient’s medical record, on Ultra Pink paper when possible.Using POLST• Any incomplete section of POLST implies full treatment for that section.Section A:• If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions

should be used on a patient who has chosen “Do Not Attempt Resuscitation.”Section B:• When comfort cannot be achieved in the current setting, the patient, including someone with “Comfort-Focused Treatment,”

should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).• Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), bi-level positive airway pressure

(BiPAP), and bag valve mask (BVM) assisted respirations.• IV antibiotics and hydration generally are not “Comfort-Focused Treatment.”• Treatment of dehydration prolongs life. If a patient desires IV fluids, indicate “Selective Treatment” or "Full Treatment.”• Depending on local EMS protocol, "Additional Orders” written in Section B may not be implemented by EMS personnel.Reviewing POLSTIt is recommended that POLST be reviewed periodically. Review is recommended when:• The patient is transferred from one care setting or care level to another, or• There is a substantial change in the patient’s health status, or• The patient’s treatment preferences change.Modifying and Voiding POLST• A patient with capacity can, at any time, request alternative treatment or revoke a POLST by any means that indicates intent

to revoke. It is recommended that revocation be documented by drawing a line through Sections A through D, writing “VOID” in large letters, and signing and dating this line.

• A legally recognized decisionmaker may request to modify the orders, in collaboration with the physician/NP/PA, based on the known desires of the patient or, if unknown, the patient’s best interests.

This form is approved by the California Emergency Medical Services Authority in cooperation with the statewide POLST Task Force. _________________________For more information or a copy of the form, visit www.caPOLST.org.___________________

SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED