Patient Intake
A patient intake form. Cross-outs, blank fields, marginal notes. The official record says she fell. The margin says everything the official record doesn't.
Patient Intake
CARTWRIGHT MEMORIAL HOSPITAL
PATIENT INTAKE FORM — GENERAL ADMISSION
Please print clearly. Complete all fields. Leave nothing blank.
DATE OF INTAKE: November 12 14, 2019
TIME: 2:47 a.m.
[marginal note, pencil: brought in by — nobody. walked in alone. no coat. november.]
PATIENT NAME: Elise Bowman Bowman- Voss
[marginal note: asked three times. different answer each time. used last response.]
DATE OF BIRTH: March 3, 19——
[field left incomplete by patient. estimated late 30s per attending.]
ADDRESS:
[left blank]
[marginal note: asked twice. second time she said "I'm not there anymore." documented as non-responsive to question.]
EMERGENCY CONTACT:
[left blank]
[marginal note: asked. she said "there isn't one." asked if there was anyone we should call. long pause. said "not anymore." documented as no emergency contact available.]
INSURANCE PROVIDER: Blue Cross Aetna
[left blank. uninsured box checked by intake coordinator.]
REASON FOR VISIT:
[typed, patient dictated:]
I fell.
[marginal note, different handwriting: patient presented with laceration to left temple, contusion to right forearm consistent with defensive posturing, bruising at various stages of healing on upper arms bilateral. "I fell" documented per patient report. See nursing note 2:52 a.m.]
[second marginal note, initialed R.V.: nursing note flagged for attending. attending notified 3:04 a.m.]
CURRENT MEDICATIONS:
[left blank]
[marginal note: patient said "nothing anymore." unclear if referring to medications or something else. documented as no current medications.]
ALLERGIES:
None known
[the word "known" crossed out by patient. replacement word not provided.]
MEDICAL HISTORY:
Please check all that apply:
☐ Diabetes
☐ Heart Disease
☐ Hypertension
☑ Depression [checkbox checked, then the word "depression" underlined twice by patient, as if confirming something, or correcting the form's casual use of the word]
☐ Anxiety
☐ Prior Surgeries
[at the bottom of the checklist, in the white space below the final checkbox, in handwriting that is different from the marginal notes, smaller, pressed harder into the page:]
there should be a box for the other thing
[marginal note: unclear what patient means. not followed up at time of intake.]
HAVE YOU SEEN A DOCTOR IN THE PAST 12 MONTHS?
Yes No
[marginal note: "yes" checked initially, then crossed out, "no" checked. when asked about the correction patient said "it doesn't count if they don't actually look at you." documented as no.]
ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING?
Please rate on a scale of 1-10.
Pain: 7 7 4 7
[the number revised twice and returned to the original, as if the patient attempted honesty, retreated from it, returned]
Dizziness: 3
Nausea:
[left blank]
[marginal note: patient stared at this question for approximately thirty seconds. moved on without answering. did not circle back.]
Difficulty breathing:
[left blank]
[same marginal note, continued: or this one.]
IN YOUR OWN WORDS, DESCRIBE WHAT HAPPENED:
[large field, lines provided for response]
I was in the kitchen. It was late. He I fell against the counter and then he said I must have hit the floor because when I got up my head was
[sentence unfinished. patient stopped writing. rest of field blank.]
[marginal note: patient handed form back at this point. said "I think that's enough." intake coordinator completed remaining fields.]
HAVE YOU FELT SAFE AT HOME?
[field added by hand to this particular form, not pre-printed, written in by intake coordinator with a different pen, slightly crooked, the handwriting of someone who added it after the fact, after reading what was above]
[patient's response, written directly below the handwritten question, in her own hand:]
I used to know what that meant.
SIGNATURE:
[signed, but not the name given at intake. a different name. the original name. the before-name. the name that appears nowhere else on this form.]
[marginal note, final note, bottom of page, the handwriting that has been here all along, small and pressed:]
she stayed. we got her a blanket. the attending came. someone sat with her.
she didn't have to be alone in the waiting room.
this is not in the official record.
this is in the margin.
the margin is where the true things go.
INTAKE COORDINATOR: R. R. Voss
TIME COMPLETED: 3:31 a.m.
DATE: November 14, 2019
[attached to the back of the form, clipped, a business card for a local shelter, handwritten on the back in the same small pressed handwriting:]
you don't have to go back.
you already know that.
we'll keep the light on.
Form retained in patient file.
Official record: laceration repaired, patient discharged.
What the official record contains: the fall.
What the official record does not contain: everything above.
The margin contains everything above.
The margin always does.
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