Discharge Planning Form

Collects the information care teams need to plan a patient's transition home and organize post-hospital support.

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Patient's Full Name

First Name

Last Name

Date of Birth

Primary Phone Number

Email Address

Gender

Male Female Other Prefer not to say

Home Address

Street Address

City

State / Province

ZIP / Postal Code

Reason for Hospitalization

Current Medical Conditions

Diabetes Hypertension Heart Disease Respiratory Condition Other

Preferred Language

Is the patient living alone?

Yes No

Do you have a caregiver or family member available to assist with post-discharge care?

Yes No

Date of Discharge

Preferred Discharge Destination

Additional Comments or Instructions

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